• This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read this notice carefully. If you have any questions, please contact our Office Privacy Officer.

    We are required by law to: (a) Make sure that health information that identifies you is kept private. (b) Give you this Notice of our legal duties and privacy practices with respect to health information about you. (c) Follow the terms of the Notice that is currently in effect.

    How we may use and disclose health information about you: (1) For treatment. (2) For payment. (3) For health care operations. (4) For Appointment reminders. (5) As required by Law. (6) To avert a serious threat to health and safety. (7) As required by the Military or Veterans and Workers Compensation. (8) Lawsuits and disputes. (9) Law enforcement. (10) Government Agencies. (1 1 ) Security Officials for Inmates. (12) Business Associates. (13) Our submission of your health information to auditors hired by third-party payers and insurers.

    Your rights regarding Health Information about you: (1) Right to Inspect and copy. (2) Right to Amend. (3) Right to an Accounting of Disclosures.. (4) Right to Request Restrictions. (5) Right to Request Confidential Communication. (6) Right to a Paper copy of this notice (full Notices is available upon request).

    Changes to the Notice: We reserve the right to change the Notice. We will post a copy of the current not ices in our facility with the current effective date on the first page.

    Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact the Privacy Officer to file a complaint.

    Acknowledgement of Receipt of this Notice: I have read this document and understand it. I consent to the use and disclosure of my health information.
  • This field is for validation purposes and should be left unchanged.