Get an electronic or paper copy of your medical record

•   You can ask to see or get an electronic or paper copy of your medical record and other health information. Ask us how to do this.

•   We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee consistent with federal and state law.

Ask us to correct your medical record

•   You can ask us to correct health information that you think is incorrect or incomplete. Ask us how to do this.

•   We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

•   You can ask us to contact you in a specific way (for example, home, or cell phone) or to send mail to a different address.

•   We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

•   You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it would affect your care. If we agree to your request, we may still share your health information if you need emergency treatment.

•   If you pay for a service or health care item 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 a law requires us to share that information.

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 will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’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.

Choose someone to act for you

•   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.

•   We will make sure the person has this authority and can act for you before we take any action.

Get a copy of this privacy notice

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

File a complaint if you feel your rights are violated

•   You can complain if you feel we have violated your rights by contacting us. Our contact information is provided below.

•   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 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/HIPAA/complaints/.

•   We will not retaliate against you for filing a complaint.

In these cases, you can talk to us to exercise your rights and make certain choices

•   You have both the right and choice to tell us to share information with your family, close friends, or others involved in your care or payment for your care.

•   In case of a disaster, we may use or disclose your health information to disaster relief organizations to coordinate your care and to notify family or friends of your location and condition. Whenever possible, we will provide you with an opportunity to agree or object to this sharing.

•   We may include your information in a directory or other internal display, which may include your name and location in the Facility as well as your general condition (e.g., good, fair, etc.), unless you opt out. If you choose to opt out from being included in our directory, that opt-out will only apply during your current stay. You will need to opt out again for any future stays.

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

In these cases, we never share your health information unless you give us written permission

•   Marketing purposes

•   Sale of your information

•   Most sharing of psychotherapy notes

In the case of fundraising

•   We may contact you for fundraising efforts, but you can tell us not to contact you again.

Treat you

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

•   We can use your health information to plan and document your care and treatment.

Example A: A doctor treating you for an injury asks another doctor about your overall health condition.

Example B: Assist with your transition of care to persons arranging for or directly providing care to you following your discharge.

Run our organization

•   We can use and share your health information to run our organization, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services, including but not limited to contacting you to schedule appointments, provide treatment alternatives or to provide information regarding health-related benefits or services you may be interested in learning about.

Bill for your services

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

Example: We give information about you to your health insurance plan so it will pay for your services.

Help with public health and safety issues

We 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

Do Research

•   We may disclose your health information to researchers for the purpose of conducting research when an Institutional Review Board (IRB) or Privacy Board has approved the research and in compliance with law governing research, or where you have provided your authorization. You may choose to participate in a research study that requires you to obtain related health care services. If you make this choice, we may share your health information with the researchers involved in the study who order the health care services as well as with your insurance plan so we may receive payment for those services that your plan agrees to cover. We may also use and share your health information with a researcher if certain parts of the information that would identify you are removed before we share it. This will only happen if the researcher agrees in writing that they will only use or share the information for permitted purposes, they will not try to contact you, and they will comply with other requirements set forth in the law.

Educate health professionals

•   We can use or share your information for the education of other healthcare professionals.

Comply with the law

•   We will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

•   If you are an organ donor, we can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

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

Address workers’ compensation, law enforcement, and other government requests

We 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.

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.

Business Associates

•   In our organization, some services are provided through contracts with business associates. When we contract with a business associate to provide services, we may disclose your health information to them so they can perform the job we have contracted with them to perform. We require business associates to sign a written agreement requiring that they comply with applicable parts of HIPAA and that they protect and safeguard your information in the same manner as HIPAA requires of us.

Health Information Exchange

•   If we participate in a Health Information Exchange (HIE), which is permitted under law, we may share your health information electronically with this exchange to provide faster access to information and improved coordination of care to assist providers and others in making more informed decisions.