OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you on how we may use and disclose
protected health information about you and describes your rights and our obligations regarding
the use and disclosure of that information. We shall maintain the privacy of protected health
information and provide you with notice of our legal duties and privacy practices with respect to
your protected health information.
We have the right to change these policies at any time. If we change our privacy policies, we will
notify you of these changes immediately. This current policy is in effect unless stated otherwise.
If the policy is changed, it will apply to all your current and past health information.
You may request a copy of our notice any time. You may contact (LLC NAME) at (ADDRESS
AND CONTACT INFO) at any time to request a copy of this privacy policy.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for
your treatment, payments, healthcare operations etc. but please be advised that not every use or
disclosure in a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you
treatment. This includes disclosing your protected health information to other medical providers,
trainees, therapists, medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate
your care. Also, the office staff may need to use and disclose your protected health information
to other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to obtain payment from an
insurance company or another third part. This may include providing an insurance company your
protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to
operate this medical practice. These activities include training students, reviewing cases with
employees, utilizing your information to improve the quality of care, and contacting you be
telephone, email, or text to remind you of your appointments.
If we have to share your protected health information to third party “business associates” such as
a billing service, if so, we will have a written contract that contains terms that will protect the
privacy of your protected health information.
We may also use and disclose your protected health information for marketing activities. For
example, we might send you a thank you card in the mail with a coupon for specialized services

or products. We may also send you information about products or services that might be of
interest to you. You can contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those
identified in this policy without your specific, written Authorization. You may give us written
authorization to use your protected health information or to disclose it to anyone for any purpose.
You can revoke this authorization at any time but will not affect the protected health information
that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for
your initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about
you to your family members or friends if we obtain your verbal agreement to do so, or if we give
you an opportunity to object to such a disclosure and you do not raise an objection. For example,
we may assume that if your spouse or friend is present during your evaluation, that we can
disclose protected professional information to this person. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we determine that it is in
your best interest based on our professional judgment if there is an urgent or emergent need.
Research; We will not use or disclose your health information for research purposes unless you
give us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to
organizations that handle organ procurement or organ, eye or tissue transplantation if it is
necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order
to prevent or control disease, report adverse events from medications or products, prevent injury,
disability or death. This information may be disclosed to healthcare systems, government
agencies, or public health authorities. We may have to disclose your protected health information
to the Food and Drug Administration to report adverse events, defects, problems, enable recalls
etc. if required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight
agencies for audits, investigations, inspections or licensing purposes. These disclosures might be
necessary for state and federal agencies to monitor healthcare systems and compliance with civil
law.
Required by Law: We will disclose protected health information about you when required to do
so by federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s
comp or similar programs.

Lawsuits: We may disclose your protected health information in response to a court action,
administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official
in response to a court order, subpoena, warrant, subject to all applicable legal requirements.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Access to medical records: You have the right to access and receive copies of your protected
health information that we use to make decisions about your care. You must submit a written
request to obtain your protected health information to the individual listed at the end of this
privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy
the protected health information and provide it to you.
Amendment: If you believe the protected health information, we have about you is incorrect or
incomplete, you may ask us to amend the information You will need to submit a written request
on why you feel the health information should be amended. We may deny your request to amend
if you did not send a written request or give a reason on why it should be amended. If we deny
your request, we will provide you a written explanation. We may deny your request if we believe
the protected health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we
disclosed your personal health information unless the disclosure was used for treatment,
payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided
in applicable federal and state laws and regulations. You must submit a written request to obtain
this “accounting of disclosures” to the individual listed at the bottom of this policy. After your
request has been approved, we will provide you the dates of the disclosure, the name of the
individual or entity we disclosed the information to, a description of the information that was
disclosed, the reason why it was disclosed, and any additional pertinent information. This
information may not be longer than (YOUR STATES STATUTE OF LIMITATIONS) years ago
prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for
this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected
health information we use or disclose about you for treatment, payment, or healthcare operations.
We shall accommodate your request except where the disclosure is required by law. We require
this be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you
about healthcare matters in a certain way and at a certain location. We must accommodate your
request if it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed
and signed it via electronic means. To obtain this copy, contact the individual at the end of this
privacy policy.

Complaints: If you believe your privacy rights have been violated, you may file a complaint
with our office. You also file a complaint with 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.