HIPAA Notice of Privacy Practices

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or healthcare operations (TPO), and for other purposes that are permitted or required by law.

Protected health information includes information about you, including demographic information, that may identify you and relates to your past, present, or future physical or mental health condition and related healthcare services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who are involved in your care and treatment for the purpose of providing healthcare services to you and obtaining payment for those services.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes coordination with third parties.

Example: Your PHI may be shared with a physician you are referred to so they have the necessary information to diagnose or treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your healthcare services.

Example: Your health plan may require relevant PHI to approve a hospital stay.

Healthcare Operations

We may use or disclose your protected health information to support business activities such as:

• Quality assessment and improvement
• Employee review and training
• Medical student education
• Licensing and compliance

Additional examples include:

• Sign-in sheets at registration
• Calling your name in the waiting room
• Appointment reminders
• Informing you about treatment options or health-related services

Other Permitted and Required Disclosures

We may use or disclose your protected health information without your authorization (except for SUD records as outlined in the Feb 15, 2026 addendum) in the following situations:

• As required by law
• Public health activities
• Communicable disease reporting
• Health oversight activities
• Abuse or neglect reporting
• FDA requirements
• Legal proceedings
• Law enforcement purposes
• Coroners and funeral directors
• Organ donation
• Research
• Criminal activity
• Military and national security

We must also disclose your PHI:

• To you upon request
• To the Secretary of the Department of Health and Human Services for compliance investigations

Provided by HCSI

Other uses and disclosures will only be made with your written authorization unless otherwise required by law. You may revoke your authorization at any time in writing, except where we have already acted on it.

Your Rights

You have the following rights regarding your protected health information:

Right to Inspect and Copy

You may inspect and obtain a copy of your PHI (fees may apply).

Exceptions include:

• Psychotherapy notes
• Legal proceedings
• Certain research data
• Information restricted by law
• Information that could cause harm
• Confidential third-party information

Right to Request Restrictions

You may request limits on how your PHI is used or disclosed.

• We must comply if the service was paid out-of-pocket in full
• You may restrict disclosure to family or others involved in your care
• Restrictions do not apply to treatment purposes

Right to Confidential Communications

You may request that we communicate with you:

• By alternative means
• At alternative locations

You may also request a paper copy of this notice at any time.

Right to Amend

You may request corrections to your PHI.

If denied:

• You may submit a statement of disagreement
• We may provide a rebuttal

Right to an Accounting of Disclosures

You may request a record of disclosures of your PHI, excluding:

• Authorized disclosures
• Treatment, payment, or operations
• Disclosures required by law
• Disclosures before April 14, 2003
• Disclosures older than six years

Right to a Paper Copy

You may obtain a paper copy of this notice even if you agreed to receive it electronically.

We reserve the right to update this notice and will provide updated copies upon request or at your next appointment.

Right to Choose a Representative

You may designate someone to act on your behalf:

• Medical power of attorney
• Legal guardian

We will verify their authority before taking action.

Complaints

If you believe your privacy rights have been violated, you may file a complaint:

• With us (via our Compliance Officer)
• With the Secretary of Health and Human Services

We will not retaliate against you for filing a complaint.

Our Responsibilities

We are required by law to:

• Maintain the privacy of your PHI
• Provide you with this notice of our legal duties and privacy practices
• Follow the terms of the notice currently in effect

Questions

If you have any questions about this notice, please contact our HIPAA Compliance Officer in person or by phone at our main office number.