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 our Privacy Contact, Gretchen Knutson, at email@example.com or 888.592-6117 x723.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by emailing us at firstname.lastname@example.org and requesting that a revised copy be sent to you.
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked during the registration process, to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, your provider will use or disclose your protected health information as described in this Section 1. Your protected health information may be used and disclosed by your provider, our administrative staff and others outside of our practice that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the RetraceHealth practice.
Your protected health information will also be routinely shared with RetraceHealth. Some of the information gathered and used by both Yellow Coriander P.S.C. and RetraceHealth may be aggregated with data form other patients, and ‘de-identified’ so that this aggregated data can be used by both Yellow Coriander, P.S.C. and RetraceHealth to improve its service offerings and for other analytical purposes. “De-identified data” cannot be traced back to a specific patient or group of patients. This aggregated data is owned by Yellow Coriander P.S.C and RetraceHealth, and is not available for your review or use.
We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances: Others Involved in Your Healthcare, Emergencies, and Communication Barriers. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include: Required By Law, Public Health, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures.
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
You may have the right to have your provider amend your protected health information.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have already accepted this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Gretchen Knutson, at email@example.com or 888.592-6117 x723 for further information about the complaint process.
This notice was last updated in January 2017.
I have read and understand this Agreement. I have had the opportunity to ask questions regarding this Agreement. I agree to these terms and conditions.
I acknowledge that I have received a copy of the RetraceHealth Notice of Privacy Practices and have had an opportunity to review it. I have also been given an opportunity to request restriction on the use and disclosure of my protected health information, as well as to request confidential treatment of communications relating to my health information.