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Notice of Privacy Practices

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.

If you have any questions about this notice, please contact the Life Choices Clinic & Care Center.

OUR OBLIGATIONS:

We are required by law to:

• Maintain the privacy of protected health information

• Give you this notice of our legal duties and privacy practices regarding health

information about you

• Follow the terms of our notice that is currently in effect

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes how we may use and disclose health information that identifies you

(“Health Information”). Except for the purposes described below, we will use and disclose

Health Information only with your written permission. You may revoke such permission by

writing to our practice Privacy Officer.

For Treatment. We may use and disclose Health Information to treat you and provide you with

treatment-related health care services. For example, we may disclose Health Information to

doctors, nurses, technicians, or other personnel, including people outside our office, who are

involved in your medical care and need the information to provide you with medical care.

For Health Care Operations. We may use and disclose Health Information for health care

operations purposes. These uses and disclosures are necessary to ensure that all of our

patients receive quality care and to operate and manage our office. For example, we may use

and disclose information to ensure the obstetrical or gynecological care you receive is of the

highest quality. We also may share information with other entities that have a relationship

with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services.

We may use and disclose Health Information to contact you to remind you that you have an

appointment with us. We may also use and disclose Health Information to tell you about

treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share

Health Information with a person who is involved in your medical care or payment for your

care, such as your family or a close friend. We also may notify your family about your location

or general condition or disclose such information to an entity assisting in a disaster relief effort.

SPECIAL SITUATIONS:

As Required by Law. We will disclose Health Information when required by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information

when necessary to prevent a serious threat to your health and safety or the health and safety

of the public or another person. Disclosures, however, will be made only to someone who may

be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates who

perform functions on our behalf or provide us with services if the information is necessary for

such functions or services. For example, we may use another company to perform billing

services on our behalf. All of our business associates are obligated to protect the privacy of

your information. They are not allowed to use or disclose any information other than as

specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health

Information to organizations that handle organ procurement or other entities engaged in

procurement, banking, or transportation of organs, eyes, or tissues to facilitate organ, eye, or

tissue donation and transplantation.

Military and Veterans. If you are an armed forces member, we may release Health Information

as required by military command authorities. We may also release Health Information to the

appropriate foreign military authority if you are a foreign military member.

Workers’ Compensation. We may release Health Information for workers’ compensation or

similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks. We may disclose Health Information for public health activities. These

activities generally include disclosures to prevent or control disease, injury, or disability; report

births and deaths; report child abuse or neglect; report reactions to medications or problems

with products; notify people of recalls of products they may be using; a person who may have

been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

and the appropriate government authority if we believe a patient has been the victim of abuse,

neglect or domestic violence. We will only make this disclosure if you agree or when required

or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency

for activities authorized by law. These oversight activities include, for example, audits,

investigations, inspections, and licensure. These activities are necessary for the government to

monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information

to provide legally required notices of unauthorized access to or disclosure of your health

information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health

Information in response to a court or administrative order. We also may disclose Health

Information in response to a subpoena, discovery request, or other lawful process by someoneinvolved in the dispute, but only if efforts have been made to tell you about the request or

obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if

the information is: (1) in response to a court order, subpoena, warrant, summons, or similar

process; (2) limited information to identify or locate a suspect, fugitive, material witness, or

missing person; (3) about the victim of a crime even if, under certain very limited

circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe

may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an

emergency to report a crime, the location of the crime or victims, or the identity, description or

location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. We may release Health Information to a

coroner or medical examiner. This may be necessary, for example, to identify a deceased

person or determine the cause of death. We also may release Health Information to funeral

directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized

federal officials for intelligence, counter-intelligence, and other national security activities

authorized by law.

Protective Services for the President and Others. We may disclose Health Information to

authorized federal officials so they may protect the President, other authorized persons, or

foreign heads of state or conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under

the custody of a law enforcement official, we may release Health Information to the

correctional institution or law enforcement official. This release would be, if necessary: (1) for

the institution to provide you with health care; (2) to protect your health and safety or the

health and safety of others; or (3) for the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT

 

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may

disclose to a member of your family, a relative, a close friend, or any other person you identify,

your Protected Health Information directly related to that person’s involvement in your health

care. If you cannot agree or object to such a disclosure, we may disclose such information as

necessary if we determine it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief

organizations that seek your Protected Health Information to coordinate your care or notify

family and friends of your location or condition in a disaster. We will provide you with an

opportunity to agree or object to such a disclosure whenever we can practically do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with

your written authorization:1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

3. Disclosures when it is sought to investigate or impose liability on individuals, healthcare

providers, or others who seek, obtain, provide, or facilitate productive health care that is lawful

under the circumstances in which such health care is provided or to identify persons for such

activities.

Other uses and disclosures of Protected Health Information not covered by this Notice or the

laws that apply to us will be made only with your written authorization. If you authorize us, you

may revoke it at any time by submitting a written revocation to our Privacy Officer, and we will

no longer disclose Protected Health Information under the authorization. However, the

revocation will not affect the disclosure we made based on your authorization before you

revoked it.

YOUR RIGHTS:

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may

be used to make decisions about your care or payment for your care. This includes medical and

billing records other than psychotherapy notes. To inspect and copy this Health Information,

you must make your request in writing to Life Choices Clinic & Care Center. We have up to 15

days to make your Protected Health Information available to you, and we may charge you a

reasonable fee for the costs of copying, mailing, or other supplies associated with your request.

We may not charge you a fee if you need the information for a claim for benefits under the

Social Security Act or any other state or federal needs-based benefit program. We may deny

your request in certain limited circumstances. If we do deny your request, you have the right to

have the denial reviewed by a licensed healthcare professional who was not directly involved in

the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information

is maintained in an electronic format (an electronic medical record or an electronic health

record), you have the right to request that an electronic copy of your record be given to you or

transmitted to another individual or entity. We will make every effort to provide access to your

Protected Health Information in the form or format you request if it is readily producible in

such form or format. If the Protected Health Information is not readily producible in the form

or format you request, your record will be provided in either our standard electronic format or,

if you do not want this form or format, a readable hard copy form. We may charge you a

reasonable, cost-based fee for the labor associated with transmitting the electronic medical

record.

You Have the Right to Get Notice of a Breach. You have the right to be notified when your

unsecured Protected Health Information is breached.

Right to Amend. If you feel that the Health Information we have is incorrect or incomplete, you

may ask us to amend the information. You have the right to request an amendment for as longas the information is kept by or for our office. To request an amendment, you must make your

request in writing to Life Choices Clinic & Care Center.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures

we made of Health Information for purposes other than treatment, payment, and health care

operations for which you provided written authorization. To request an accounting of

disclosures, you must write to Life Choices Clinic & Care Center.

Right to Request Restrictions. You have the right to request a restriction or limitation on the

Health Information we use or disclose for treatment, payment, or health care operations. You

also have the right to request a limit on the Health Information we disclose to someone

involved in your care or the payment for your care, like a family member or friend. For

example, you could ask that we not share information about a particular diagnosis or treatment

with your spouse. To request a restriction, you must make your request in writing to Life

Choices Clinic & Care Center. We are not required to agree to your request unless you ask us to

restrict the use and disclosure of your Protected Health Information to a health plan for

payment or health care operation purposes. Such information you wish to restrict pertains

solely to a health care item or service you have paid us “out-of-pocket” in full. If we agree, we

will comply with your request unless the information is needed to provide emergency

treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested

that we not bill your health plan) in full for a specific item or service, you have the right to ask

that your Protected Health Information concerning that item or service not be disclosed to a

health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we

communicate with you about medical matters in a certain way or at a certain location. For

example, you can ask that we only contact you by mail or at work. To request confidential

communications, you must make your request in writing to Life Choices Clinic & Care Center.

Your request must specify how or where you wish to be contacted. We will accommodate

reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You

may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this

notice electronically, you are still entitled to a paper copy.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and make the new notice apply to the Health

Information we already have and any information we receive in the future. We will post a copy

of our current notice at our office. The notice will contain the effective date on the first page,

in the top right-hand corner.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our office or

the Secretary of the Department of Health and Human Services. Contact the Life Choices Clinic

& Care Center's Privacy Officer to file a complaint with our office. All complaints must be made

in writing. You will not be penalized for filing a complaint.

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