We will use and disclose your protected health and personal information to provide, coordinate or manage your healthcare and any related services. This includes, but not limited to, the coordination or management of your healthcare with a third-party. For example, we may disclose your protected health or personal information, as necessary, if, as a result of our services, you require treatment by another physician. Your protected health and personal information may be provided and/or released to such physician to ensure that the physician has the necessary information to diagnose or treat you.


Your protected health and personal information will be used, if requested, to obtain payment services by this practice. For example, if you desire to finance the cost of your treatment, this may involve disclosing protected, personal, and private information to a third party in order to secure financing.


We may use or disclose, as needed, your protected health and personal information in order to support the business activities of this office. These activities include, but not limited to, quality assessment activities; employment review activities; licensing; and conducting or arranging for other business activities. In addition, we may also use or disclose your protected health or personal information as necessary to contact you to provide (as applicable) appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. We may use or disclose your protected health or personal information in certain situations where such disclosures are required by law, without your authorization or consent. Other uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke in writing any authorization you have given us except to the extent that we have already taken actions in reliance upon your prior authorization.


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:

  • 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 any case we never sell or use your information for marketing purposes without your written permission. We may contact you for fundraising efforts, but you can tell us not to contact you again.


You have the following rights with respect to your protected health information which we explain below:

  • You can request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
  • The right to reasonably request to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
  • The right to ask us to amend or correct your protected health information. We may deny your request but will tell you why in writing within 60 days.
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
  • The right to receive an accounting of disclosures of protected health information for the six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
  • The right to obtain a paper copy of this notice from us upon request.
  • File a complaint if you believe your privacy rights have been violated. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting We will not retaliate against you for filing a complaint.


  • We are required by law to 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 in writing at any time.
  • If you have any questions or concerns regarding this notice or your protected health information, you may contact our office at (786) 648-7359, or email us at