PRIVACY STATEMENT

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.

Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we: • Tell
family and friends about your condition (those you have designated to
receive such information)
• Provide disaster relief
• Market our services and sell your information
• Raise funds

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Our Uses and Disclosures
We may use and share your information necessary to conduct business and as required
by law, such as to:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Address workers’ compensation, law
enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Choices
For certain health information, you can tell us your choices about what we share. If
you have a clear preference for how we share your information, talk to us. Tell us what
you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your
care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead
and share your information if we believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat You
We can use your health information and share it with other professionals who are
treating you. Example: A clinician treating you asks your doctor about your overall
health condition.
Run Our Organization
We can use and share your health information to run our organization, improve your
care, and contact you when necessary. Example: We use health information about you
to manage your treatment and services.
Bill For Your Services
We can use and share your health information to bill and get payment from health
plans or other entities. Example: We give information about you to your health
insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways
that contribute to the public good, such as public health and research.

We have to meet many conditions in the law before we can share your information for
these purposes.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with
the Department of Health and Human Services if it wants to see that we’re
complying with federal laws.
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative
order, or in response to a subpoena.
Our Responsibilities
• We will maintain the privacy and security of your protected health
information.
• We will let you know promptly if a breach occurs that may have
compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and
give you a copy of it.
• We will not use or share your information other than as described here unless
you tell us we can in writing. If you tell us we can, you may change your mind
at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information
we have about you. The new notice will be available upon request, on our web site,
and we will mail a copy to you.
Effective Date of this Notice: 2022