NOTICE OF PRIVACY PRACTICES
Effective November 2022
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO SUCH
INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand are committed to ensuring your privacy and maintaining the
confidentiality of your medical information. We make a record of all medical care we
provide and may receive similar records from others. We use these records to provide or
enable other health care providers to provide quality medical care and to enable us to
meet our professional and legal obligations to operate our medical clinic. We are
required by law to maintain the privacy of protected health information, to provide
individuals with notice of our legal duties and privacy practices with respect to protected
health information, and to notify affected individuals following any unauthorize release
of protected health information. This notice describes how we use and disclose your
medical information as well as your rights and our legal obligations with respect to your
TABLE OF CONTENTS
A. How This Medical Clinic May Use or Disclose Your Health Information
B. When This Medical Clinic May Not Use or Disclose Your Health Information
C. Your Health Information Rights
1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper or Electronic Copy of this Notice
D. Changes to this Notice of Privacy Practices
A. How This Medical Clinic May Use or Disclose Your Health Information
Our clinic collects health information about you and stores it electronically. This information is
your medical record, and while it is the property of this clinic, the information in these records
belongs to you. The law permits us to use or disclose your health information for the following
1. Treatment. We use your medical information to provide you medical care. We
disclose medical information to our staff and others who are involved in providing your
care. For example, we may share your medical information with other physicians or
other health care providers who will provide services that we do not provide. We may
also share this information with a laboratory that performs a test for you.
2. Payment. We use medical information about you to obtain payment for the services we
provide. We may also disclose information to other health care providers to assist them
in obtaining payment for services they have provided to you.
3. Health Care Operations. We may use and disclose medical information about you to
operate our medical clinic. For example, we may use and disclose this information to
review and improve the quality of care we provide, or the competence and
qualifications of our professional staff. Or we may use and disclose this information to
get your health plan to authorize services or referrals. We may also use and disclose
this information as necessary for medical reviews, legal services and audits, including
fraud and abuse detection and compliance programs and business planning and
management. We may also share your medical information with our "business
associates," such as our billing service, that perform administrative services for us. We
have a written contract with each of these business associates that contains terms
requiring them and their subcontractors to protect the confidentiality and security of
your protected health information. We may also share your information with other
health care providers, health care clearinghouses or health plans that have a relationship
with you, when they request this information to help them with their quality assessment
and improvement activities, their patient-safety activities, their population-based efforts
to improve health or reduce health care costs, their protocol development, case
management or care-coordination activities, their review of competence, qualifications
and performance of health care professionals, their training programs, their
accreditation, certification or licensing activities, or their health care fraud and abuse
detection and compliance efforts. We may also share medical information about you
with the other health care providers, health care clearinghouses and health plans that
participate with us in "organized health care arrangements" (OHCAs) for any of the
OHCAs' health care operations. OHCAs include hospitals, physician organizations,
health plans, and other entities which collectively provide health care services. A listing
of the OHCAs we participate in is available from the Privacy Official.
4. Sign In Sheet. We may use and disclose medical information about you by having you
sign in when you arrive at our office. We may also call out your name when we are
ready to see you.
5. Notification and Communication with Family. We may disclose your health
information to notify or assist in notifying a family member, your personal
representative or another person responsible for your care about your location, your
general condition or, unless you had instructed us otherwise, in the event of your death.
In the event of a disaster, we may disclose information to a relief organization so that
they may coordinate these notification efforts. We may also disclose information to
someone who is involved with your care or helps pay for your care. If you are able and
available to agree or object, we will give you the opportunity to object prior to making
these disclosures, although we may disclose this information in a disaster even over
your objection if we believe it is necessary to respond to the emergency circumstances.
If you are unable or unavailable to agree or object, our health professionals will use
their best judgment in communication with your family and others.
6. Marketing. Provided we do not receive any payment for making these
communications, we may contact you to give you information about products or
services related to your treatment or care coordination, or to direct or recommend other
treatments, therapies, health care providers or settings of care that may be of interest to
you. We may also encourage you to maintain a healthy lifestyle and get recommended
tests, participate in a disease management program, provide you with small gifts, tell
you about government sponsored health programs or encourage you to purchase a
product or service when we see you, for which we may be paid. We may receive
compensation which covers our cost of communicating with you about a drug or
biologic that is currently prescribed for you. We will not otherwise use or disclose your
medical information for marketing purposes or accept any payment for other marketing
communications without your prior written authorization, and we will stop any future
marketing activity to the extent you revoke that authorization.
7. Sale of Health Information. We will not sell your health information without your
prior written authorization. The authorization will disclose that we will receive
compensation for your health information if you authorize us to sell it, and we will stop
any future sales of your information to the extent that you revoke that authorization.
8. Workers’ Compensation. We may disclose your health information as necessary to
comply with workers’ compensation laws. For example, to the extent your care is
covered by workers' compensation, we will make periodic reports to your employer or
workers compensation insurer about your condition. We are also required by law to
report cases of occupational injury or occupational illness to the employer or workers'
9. Change of Ownership. In the event that this medical clinic is sold or merged with
another organization, your health information/record will become the property of the
new owner, though you will maintain the right to request that copies of your health
information be transferred to another medical group.
10. Breach Disclosure. In the case of a breach of unsecured protected health information,
we will notify you as required by law. If you have provided us with a current e-mail
address, we may use that e-mail address to contact you. We may also provide
notification by other appropriate methods.
11. Legal Requirements. As required by law, we will use and disclose your health
information, but we will limit our use or disclosure to the relevant requirements of the
law. When the law requires us to report abuse, neglect or domestic violence, or respond
to judicial or administrative proceedings, or to law enforcement officials, we will
further comply with the requirement set forth below concerning those activities.
12. Public Health. We may, and are sometimes required by law, to disclose your health
information to public health authorities for purposes related to: preventing or
controlling disease, injury or disability; reporting child, elder or dependent adult abuse
or neglect; reporting domestic violence; reporting to the Food and Drug Administration
problems with products and reactions to medications; and reporting disease or infection
exposure. When we report suspected elder or dependent adult abuse or domestic
violence, we will inform you or your personal representative promptly unless in our
best professional judgment, we believe the notification would place you at risk of
serious harm or would require informing a personal representative we believe is
responsible for the abuse or harm.
13. Health Oversight Activities. We may, and are sometimes required by law, to disclose
your health information to health oversight agencies during the course of audits,
investigations, inspections, licensure and other proceedings, subject to the limitations
imposed by law.
14. Judicial and Administrative Proceedings. We may, and are sometimes required by
law, to disclose your health information in the course of any administrative or judicial
proceeding to the extent expressly authorized by a court or administrative order. We
may also disclose information about you in response to a subpoena, discovery request
or other lawful process if reasonable efforts have been made to notify you of the request
and you have not objected, or if your objections have been resolved by a court or
15. Law Enforcement. We may, and are sometimes required by law to, disclose your
health information to a law enforcement official for purposes such as identifying or
locating a suspect, fugitive, material witness or missing person, complying with a court
order, warrant, grand jury subpoena and other law enforcement purposes.
16. Coroners. We may, and are often required by law, to disclose your health information
to coroners in connection with their investigations of deaths.
17. Public Safety. We may, and are sometimes required by law, to disclose your health
information to appropriate persons in order to prevent or lessen a serious and imminent
threat to the health or safety of a particular person or the general public.
B. When This Clinic May Not Use or Disclose Your Health Information.
Except as described in this Notice of Privacy Practices, this medical clinic will, consistent with
its legal obligations, not use or disclose health information which identifies you without your
written authorization. If you do authorize this clinic to use or disclose your health information for
another purpose, you may revoke your authorization in writing at any time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You have the right to request
restrictions on certain uses and disclosures of your health information by a written
request specifying what information you want to limit, and what limitations on our use
or disclosure of that information you wish to have imposed. If you tell us not to disclose
information to a commercial health plan concerning health care items or services for
which you paid for in full out-of-pocket, we will abide by your request, unless we must
disclose the information for treatment or legal reasons. We reserve the right to accept or
reject any other request and will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that
you receive your health information in a specific way or at a specific location. For
example, you may ask that we send information to a particular e-mail account or to
your work address. We will comply with all reasonable requests submitted in writing
which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health
information, with limited exceptions. To access your medical information, you must
submit a written request detailing what information you want access to, whether you
want to inspect it and/or receive a copy, and if you want a copy, your preferred form
and format. We will provide copies in your requested form and format if it is readily
producible, or we will provide you with an alternative format you find acceptable, or if
we can’t agree and we maintain the record in an electronic format, your choice of a
readable electronic or hardcopy format. We will also send a copy to any other person
you designate in writing. We will charge a reasonable fee which covers our costs for
labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing
an explanation or summary. We may deny your request under limited circumstances. If
we deny your request to access your child's records or the records of an incapacitated
adult you are representing because we believe allowing access would be reasonably
likely to cause substantial harm to the patient, you will have a right to appeal our
4. Right to Amend or Supplement. You have a right to request that we amend any part
of your health information that you believe is incorrect or incomplete. Any such request
must be made in writing and include the reasons you believe the information is
inaccurate or incomplete. We are not required to change your health information as you
instruct us, and should we determine your changes are not appropriate and accurate, we
will provide you with the reasons for our denial and how you can disagree with that
denial. We may deny your request if we do not have the information, if we did not
create the information (unless the person or entity that created the information is no
longer available to make the amendment), if you would not be permitted to inspect or
copy the information at issue, or if the information is accurate and complete as is. If we
deny your request, you may submit a written statement of your disagreement with that
decision, and we may, in turn, prepare a written rebuttal. All information related to any
request to amend will be maintained and disclosed in conjunction with any subsequent
disclosure of the disputed information.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of
disclosures of your health information made by this clinic with the following
exceptions where we do not have to account for the disclosures provided to you or
pursuant to your written authorization, or as described in this notice in (i) the
paragraphs addressing Treatment, Payment, Health Care Operations, Notification and
Communication with Family and Public Health, all within Section A of this Notice of
Privacy Practices, (ii) disclosures for purposes of research or public health which
exclude direct patient identifiers, (iii) which are incident to a use or disclosure
otherwise permitted or authorized by law or (iv) the disclosures to a health oversight
agency or law enforcement official to the extent this clinic has received notice from
such agency or official that providing this accounting would be reasonably likely to
impede their activities.
6. Right to a Paper or Electronic Copy of this Notice. You have a right to receive a
notice of our legal duties and privacy practices with respect to your health information,
including a right to a paper copy or electronic copy of this Notice of Privacy Practices,
even if you have previously requested its receipt by e-mail.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in accordance with
applicable law. Until such amendment is made, we are required by law to comply with the terms
of this Notice as they currently exist. After an amendment is made, the revised Notice of Privacy
Protections will apply to all protected health information that we maintain, regardless of when it
was created or received. We will keep a copy of the current notice and it will be available to you
at each appointment. We will also post the current notice on our website.
Complaints about this Notice of Privacy Practices or how this clinic handles your health
information may be directed to Dr. Carissa Abe, D.C. or James Van Doren, our principal
manager. Both can be reached through the clinic’s primary phone number (602-971-2148) or by
email at email@example.com.
If you are not satisfied with the manner in which this office handles a complaint, you may submit
a formal complaint to:
The form for such requests may be found at:
You may not be penalized in any way for filing a complaint.