HIPAA Notice of Privacy Practices


Your Rights 

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

• You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. If you ask, I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.


• You can ask me to correct health information about you that you think is incorrect or incomplete. If you ask, I may say “no” to your request, but I’ll tell you why in writing within 60 days.

• You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.


• You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.

• You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before I take any action.

• You can complain if you feel I have violated your rights by contacting me using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 877-696-6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.

Your Choices 

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.

In these cases, you have both the right and choice to tell me to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases I never share your information unless you give me written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

My Uses and Disclosures 

I typically use or share your health information in the following ways:


• I can use your health information and share it with other professionals who are treating you.

• I can use and share your health information to run my practice, improve your care, and contact you when necessary.

• I can use and share your health information to bill and get payment from health plans and other entities.

• I am also allowed or required to share your information in ways that contribute to the public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

I can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

I can use or share your information for health research.

I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law.

I can share health information about you with organ procurement organizations.

I can share health information with a coroner, medical examiner, or funeral director when an individual dies.

I can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

I can share health information about you in response to a court or administrative order, or in response to a subpoena.

My Responsibilities 

I am required by law to maintain the privacy and security of your protected health information.

I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

I must follow the duties and privacy practices described in this notice and give you a copy of it.

I will not use or share your information other than as described here unless you tell me I can in writing.

If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice 

This notification takes effect January 1, 2014 and remains in force until replaced. I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office, and on my web site.

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