HIPPA Notice

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. This Notice takes effect 05/01/2012, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. The new terms of our Notice will be effective for all health information that we maintain, including health information we created or received before we made the changes. You may request a copy of our Notice at any time.

We routinely use and disclose health information about you for the following purposes without special permission:

Treatment: We may use or disclose your health information to a physician, dentist, hygienist or other healthcare practitioner in order to provide appropriate treatment, referrals and to monitor the service provided to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you including submitting claims to your insurance carrier. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations may include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

We may use or disclose your health information when required under the circumstances listed below.

• As necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.
• As required by law including by statute, regulation, court orders or subpoenas.
• To public health authorities authorized to receive such information for preventing or controlling disease, injury, or disability.
• To health oversight agencies for legally authorized health oversight activities.
• To appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
• To entities subject to FDA regulation regarding FDA regulated products or activities.
• To individuals who may have contracted or been exposed to a communicable disease when required.
• To employers for a work-related illness or injury, workers’ compensation or workplace related medical surveillance.
• In a judicial or administrative proceeding through a court order or administrative tribunal.
• To law enforcement under the following circumstances: to identify or locate a suspect, fugitive, material witness, or missing person; in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; to alert law enforcement of a person’s death, if the we suspect that criminal activity caused the death; when we believe that protected health information is evidence of a crime that occurred; and in a medical emergency, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.
• To funeral directors and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.
• For health related research, subject to the approval of an Institutional Review or Privacy Board.
• For certain essential government functions such as: military missions, conducting intelligence and national security activities, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.
• With disaster relief organizations.
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures.
• To business associates who perform health care operations for us and who commit to respect the privacy of your health information.
  Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information using our professional judgment that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, dental supplies, x-rays, or other similar forms of health information.

PATIENT RIGHTS

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to the address above to obtain access to your health information. If you request copies, we will charge you $2 for each page, $40 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. We are not required by law to change your health information. If we agree with your request we will amend your records within 60 days of receipt of a written request. You have the right to request, in writing, that we place additional restrictions on our use or disclosure of your health information (except in an emergency). We are not required to agree to these additional restrictions.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We have 60 days to complete this request.

Alternative Communication: You have the right to request, in writing, that we communicate with you about your health information by alternative means (phone at work) or to alternative locations. Your request must be reasonable and specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

QUESTIONS AND COMPLAINTS: If you have questions or concerns regarding our compliance with this policy, you may complain to us using the contact information listed at the beginning of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.