Your Information. Your Rights. Our Responsibilities.
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
As a Cash-Based Clinic, we are not subject to HIPPA. However, we take your privacy very seriously and we do follow HIPPA standards to ensure your information is secure. All patient and health coaching data is stored in a HIPPA-compliant cloud-based platform. Clinic email is a HIPPA-compliant product as well.
Our Uses and Disclosures
Protected health information (PHI) is your information created or received by a healthcare provider that relates to your past, present or future physical or mental health or condition, to the provision of health care to you, or to payment for your health care.
How do we typically use or share your health information? We may use or disclose your protected health information without your consent or authorization for the purposes of your treatment, for payment purposes, and for certain administrative and other health care operations. We typically use or share your health information in the following ways:
- Treatment – We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
I acknowledge and understand that this office may contact and survey me via e-mail regarding my satisfaction and outcomes. I understand that an independent vendor(s) may assist with this data collection. I understand that in addition to the confidential survey, this office or their designated vendor may also send an automated email to allow me to rate and review my provider online through sites like Google, Yelp, Keet, etc. voluntarily and publicly. I acknowledge that my responses, like other online responses, may be published on the respective review site(s) and will be publicly disclosed and accessible to anyone who accesses that site. I understand that reviews are optional, and I will not include any sensitive, personal, identifying, or medial information that I do not wish to be publicly disclosed in an online review, i.e., name, contact information, social security number, health history, diagnosis, medications, etc. When submitting a survey or review, I agree
- We will maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. If you change your mind, you have the right to take back or “revoke” your authorization at any time by submitting a revocation in writing. We are unable to take back any use or disclosure that we have taken an action in reliance on the authorization for use or disclosure as previously indicated.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care – if you consent, do not object, or we reasonably infer that there is no objection, we may disclose health information about you to a family member, personal representative or other person identified by you who is involved in your care.
Your Rights
When it comes to your health information, you have certain rights. You will need to make a written request to exercise these rights. Forms for these purposes are available in our office(s), or you may call the office(s) to request the forms be sent to you.
Get a copy of your medical record – With a few exceptions (such as records compiled in anticipation of litigation), you have a right to inspect or receive copies of your health information. We will provide a copy or summary of your health information, usually within 30 days of your request, we may charge a reasonable cost-based fee.
Ask us to limit what we use or share – You can ask us not to use or share certain health information.
If you pay for services or health care items out of pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say yes unless the law requires us to share that information.
- Comply with the law – We 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 we’re complying with federal privacy law.
- Respond to lawsuits and legal actions – We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Request confidential communications – You have the right to ask that we contact you in a specific way (for example, home or office phone) or to send mail to a different address. Request must be made in writing; you do not need to give us a reason for your request. We will say yes to all reasonable requests.
Ask us to correct your medical record – If you believe that your information is incorrect or incomplete, you have the right to request an amendment if the information is maintained by us. We may say “no” to your request, but we will tell you why in writing within 60 days.
Get a list of those with whom we’ve shared information – You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why.
We reserve the right to change our Notice of Privacy Practices and to make the new provisions effective for all protected health information we maintain, including protected health information received in the past as well as received after the effective date of the new Notice. You may also obtain a copy by emailing or calling our clinic and or by asking for one the next time you are in our office.