Privacy Policy

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review carefully.

1. Your medical records are used to provide treatment, bill and receive payments, and

conduct healthcare operations. Examples of these activities include but not limited to

review of treatment records to ensure appropriate care, electronic or mail delivery of

billing for treatment to you or other authorized payers, appointment reminder telephone

calls, and records review to ensure completeness and quality of care. Use and

disclosure of medical records is limited to the internal used outlined above except

required by law or authorized by the patient or legal guardian.

2. Federal and State laws require abuse, neglect, domestic violence and threats to be

reported to social services or other protective agencies. If such reports are made they

will be disclosed to you or your legal representative unless disclosure increases risk of

further harm.

3. Disclosed information will be limited to the minimum necessary. You may request an

account for any uses or disclosures other than those described in Sections 1 and

Sections 2.

4. You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in

writing at any time. Psychotherapy notes are part of your medical records. We have 30

days to respond to a disclosure request and 60 days if the records are stored off site.

5. You may request corrections to your records.

6. A request for disclosure may be denied under the following circumstances: disclosure

would likely endanger the life or physical safety of you or another person, requested

information references other persons, except another healthcare provider, or if released

to a legal representative would likely result in harm.

7. If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request review of the denial. A review will be conducted by another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.

8. You may request that we restrict uses and disclosures outlined in Section 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while

required by law or in an emergency. We may also revoke such restrictions but

information gathered while the restriction was in place will remain restricted by such an

agreement.

9. If you wish to complain about privacy related issues you may contact the Secretary of

the Department of Health and Human Services, Hubert H. Humphrey Building, 200

Independence Avenue SW, Washington DC, 20201. In any case there will not be any

retaliation against you or your legal representative for filing a complaint.

10. This agreement may be modified or amended as required by law or in the course of

health care operations.