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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 long as 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.