THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED, AS WELL AS HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures of Personal Health Information
We are committed to protecting the privacy of your personal health information. However, there are circumstances under which we may use or disclose this information as permitted or required by law. Note that this notice does not list every possible use or disclosure, but all of the ways that we may use and disclose your personal health information will fall into one of these categories.
I. Your authorization
Except as outlined below, we will not use or disclose your personal health information for any purpose unless you authorize such use or disclosure in writing. You have the right to revoke that authorization, in writing, at any time.
II. Treatment
Your personal health information may be used and disclosed as necessary to support your treatment. For instance, your clinician may consult with another healthcare professional in order to provide you with the best possible care.
III. Payment
Your personal health information may be used and disclosed as necessary for payment purposes. For instance, we may send information regarding your diagnosis or treatment to you or to another person who is financially responsible for the services you receive through our clinic.
IV. Business associates
Certain aspects of our services are performed through contracts with outside persons or organizations, such as legal services. At times it may be necessary for us to share your personal health information with these individuals. In these cases, we require our business associates to appropriately safeguard the privacy of your information.
V. Lawsuits and disputes
If you are involved in a lawsuit, we may be required to disclose your personal health information in response to a subpoena. Additionally, if you pursue a lawsuit against our clinic, we may use and disclose relevant personal health information to respond to the suit.
VI. Other uses and disclosures
We are permitted or required by law to make certain other uses or disclosures of your personal health information without your authorization. Subject to conditions specified by law, we may release your personal health information:
Your Rights Regarding Your Personal Health Information
I. Requesting restrictions
You have the right to ask that we not use or disclose your personal health information for treatment, payment, or healthcare purposes. We are not required to agree to your request, and we may decline your request if we believe it would negatively impact your healthcare.
II. Receive communication by alternative means and at alternative locations
You have the right to ask us to contact you in a specific way (e.g., at a home or mobile phone) and at a particular location (e.g., at a home or office address). We will agree to all reasonable requests, though you must submit these requests in writing.
III. Receive an accounting of disclosures
You generally have the right to receive a list of the instances in which we have disclosed your personal health information without your consent or authorization. You must submit a written request for this accounting.
IV. View and obtain copies of your records
In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing, and we may charge a fee for copying and mailing costs. We may deny your request to inspect and copy in some circumstances, and we may decline to provide you access to certain psychotherapy notes or information compiled in anticipation of a civil, criminal, or administrative proceeding.
V. Request an amendment
If you believe that there is an error or omission in your file, you have the right to request, in writing, that we correct or add the relevant information. We may deny your request, particularly if you ask us to amend information that was not created by your clinician, is not part of the medical information kept by your clinician, is not part of the information that you would be permitted to inspect and copy, or is not accurate and complete.
VI. Receive a copy of this notice
You have the right to receive a paper copy of this notice. You may request a copy of this notice at any time.
Our Responsibilities
I. Maintain the privacy of your personal health information
We are required by law to maintain the privacy and security of your personal health information.
II. Notify you of a breach
We will promptly alert you if a breach occurs that may have compromised the privacy of security of your information.
III. Follow this notice
We must follow the duties and privacy practices described in this notice, and we must provide you with a copy of it.
Other Information
We reserve the right to make changes to our policies, including this notice, which are effective for past, current, and future information collected about you. Should changes be made to this notice, a new copy will be sent to you electronically. Copies of the current notice are available upon request.
If you believe that your privacy rights have been violated, you may file a complaint. You may do this by (1) submitting your complaint in writing to our office or (2) sending a written complaint to the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
For more information regarding matters covered by this notice, or to file a complaint, you may contact Dr. Erin Palmwood in writing or by telephone at (540) 216-2046.
Acknowledgement of Receipt of Notice of Privacy Practices
Your signature below indicates that you have been provided a copy of our Notice of Privacy Practices and have read, understood, and agree to the terms contained in this document.
Effective Date: 03/16/2023
