• maintain the privacy of protected health information;
• provide you with this notice of our legal duties and privacy practices with respect to your health information;
• abide by the terms of this notice;
• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
• accommodate reasonable requests that you may make to communicate health information by alternative means or at alternative locations; and
• obtain written authorization to use or disclose your health information for reasons other than those identified in this notice and permitted under law.

• The right to request that we place additional restrictions on our uses and disclosures of your protected health information. This means you may ask us not to disclose any part of your protected health information to family members or friends who may be involved in your care. You may also request that your protected health information not be disclosed for treatment, payment or healthcare operations. Your request must be in writing, and state the specific restriction requested and to whom you want the restriction to apply. However, we are not obligated to agree to impose any such additional restrictions. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional.

• The right to access, inspect and copy the protected information pertaining to you that we maintain in our files. However, under federal law, you may not inspect or copy the following records:  psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; protected health information that is subject to laws that prohibits access to protected health information.

• You have the right to have us correct or amend any information that we create in error. Request to access or amend your health information should be sent to the Privacy Committee at the address provided in the Contact Information section of this notice. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

• You have the right to receive an accounting of the disclosures of your personal health information that we make for purposes other than activities related to your treatment or our payment functions or other health care operations.

• You have the right to request that you receive confidential communications of personal health information from us by alternative means or at an alternative location.

• You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

• Information that we obtain directly from you, in conversations or on forms that you fill out.
• Information that we obtain as a result of our transactions with you.
• Information that we obtain from your medical records or from medical professionals.
• Information that we obtain from other entities, such as health care providers or other insurance companies, in order to service your policy or carry out other insurance-related needs.

• To carry out treatment functions:  We will use or disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you; such as your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you.

• To carry out payment functions:  We may use or disclose your health information without your permission to carry out activities related to obtaining reimbursement for your health care, determining coverage, and benefits under your policy. Such functions may include reviewing health care services with respect to medical necessity, appropriateness of care, or justification of charges. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

• To carry out certain health care operations:  We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical students that see patients at our offices. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
  
  We would like to inform you that we use an outside agency to conduct patient satisfaction surveys. Only demographic information is disclosed to them and no health information except your doctor’s name is given. If you do not wish to receive these surveys in the future, please let us know in writing at the address given below in the Contact Information section. Please include your name, address, and date of birth so we can insure we have the correct account. Also, we bill on family accounts, which means that other family members in your household will also be able to access account information on statements.  If you would like to be moved to your own personal account, please send us a request in writing along with your name, address, phone number, and insurance information. We will need this information to verify we have the correct patient, and to set up the new account.

• In situations permitted or required by law:  We also may use or disclose your protected health information without your written permission for other purposes permitted or required by law, including the following:

1. As authorized by and to the extent necessary to comply with workers compensation or other no-fault laws.
2. To a health oversight agency for activities including audits or civil, criminal or administrative proceedings.
3. To a public health authority for purposes of public health activities (such as to the FDA to report consumer product defects).
4. To a law enforcement official for law enforcement purposes, in response to a court order, or in the course of any judicial or administrative proceeding.
5. To organ procurement organizations, or to other entities for approved research purposes.
6. To a government authority, including social service or protective service agencies, authorized to receive reports of abuse, neglect or domestic violence.

• For Purposes For Which We Have Obtained Your Written Permission: All other uses or disclosures of your protected health information will be made only with your written permission, and you may revoke any permission that you give us at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.