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:

Your Choices
You have some choices in the way that we use and share information as we:

Our Uses and Disclosures
We may use and share your information as we:

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights
and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

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 in the situations described below, 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:

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 doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, 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. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
We can share health information about you for certain situations such as:

Our Responsibilities

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, in our office, and on our web site.