What rights do I have about by
Protected Health Information (PHI)?
You have the right to consent to the use and disclosure of your PHI for
the limited purpose of diagnosing you and administering and paying for your
You have the right to see and copy your PHI. Exceptions to this
information are psychotherapy notes; information prepared for certain legal
proceedings; and information maintained by clinical laboratories.
You have the right to request that we amend your PHI.
You have the right to be informed about and to share your PHI in a
confidential manner chosen by you. The manner you choose must be
possible for us to do.
You have the right to restrict how we use and disclose your PHI. We
do not have to agree to your restrictions under certain circumstances.
If we do agree, we must follow your restrictions.
You have the right to obtain a copy of a record of certain disclosures of
your PHI that we make. If you request a copy of the information, we may
charge a reasonable fee for the costs of copying, mailing or other office
supplies associated with your request.
You have the right to have a copy of this Privacy Notice. We may
change the terms of this Privacy Notice from time to time. You can
always get a copy of the current Privacy Notice by requesting it from the
Client Rights Officer.
What can be done with my information if
I consent to disclose it for my diagnosis or to administer and pay for my
With your consent, we can share information about your health with other
specialists so that you can receive the most appropriate care.
With your consent, we can share information about when and for what
purpose you were seen, so that we can be paid for treating you.
With your consent, we can share information with other healthcare entities
to ensure that you obtain the correct diagnosis.
Can I revoke my consent?
Yes. You can revoke your consent. you must do so in writing
and bring it to us so that we can stop using and disclosing your PHI. We
are permitted to use and disclose your PHI based on the consent until we
receive your revocation in writing. However, if you revoke your consent,
we reserve the right to refuse to provide further treatment to you, on the
basis of your refusal to allow us to share your information for purposes of
treatment, payment, and healthcare operations.
What can be done with my information if
I authorize its disclosure for other purposes?
With your permission, we can share your PHI for reasons other than to
diagnose you and to administer pay for your treatment.
Can I revoke my authorization?
Yes. You can revoke your authorization. You must do so in
writing and bring it to us so that we can stop using your PHI. We are
permitted to share your PHI based on your authorization until we receive your
revocation in writing.
Are there any circumstances when my
information can be shared without my consent or authorization?
Yes. Your PHI can be shared without your prior consent or
In an emergency as long as consent is obtained as soon as possible;
When required by law;
When there are substantial communication barriers and it is reasonable to
believe that you are giving your consent or authorization;
When required to do so to administer payment for your treatment.
What about any other uses of my
Other uses and disclosures of medical information not covered by this
notice, or the laws that apply to us, will be made only with your written
permission. You understand that we are unable to take back any
disclosures we have already made with your permission, and that we are
required to retain records of the care that we provided for you.
What will you do to my health
We will maintain the privacy of your PHI as required by law. At your
request, we will provide you with a Privacy Notice containing our legal
responsibilities and privacy practices regarding PHI.
We will follow the terms of the Privacy Notice currently in effect.
We reserve the right to change the terms contained in this privacy notice.
If we do this, it will affect all PHI maintained by us. We will notify
you that we have changed the Privacy Notice by posting it in our offices.
What can I do if I have questions or
want to complain about the use and disclosure of my Protected Health Information
All questions and complaints about the use and disclosure of your PHI may
be directed to the Client Rights Officer at 330-424-9573.
We may not retaliate against you for complaining about the use
and disclosure of your Protected Health Information.