Notice of Privacy Practices

All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.

Uses and Disclosure

• Your protected health information is accessed and used for healthcare related purposes only.
• Your protected health is never sold, rented, transferred, exchanged and/or used for non-healthcare related purposes including marketing activities without your written consent.
• Your protected health information is disclosed to third party entities without your written authorization for the purpose of treatment, to obtain payment for each treatment, and for healthcare operations.

Certain Circumstances
Your protected health information can be disclosed without your written consent and authorization in certain limited circumstances:

• Medical emergencies
• In situations required by law
• Individuals involved in your care
• When requested by a public health agency
• When requested by a law enforcement agency

For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization to disclose protected health information, you can revoke that authorization in writing at any time.

Patient Rights

• You have the right to request in writing to inspect and/or receive a copy of your health information.
• You have the right to request an alternate means or location to receive communications regarding your health information.
• You have the right to request in writing an accounting of certain disclosures of your health information that were made in this office.
• You have the right to request in writing to amend, correct, or delete any recorded health information within our possession.

*Conditions and limitations may apply; obtain additional information from front desk

Changes to this notice: We reserve the right to change privacy practice and the conditions of this notice at any time and without notice. In the event of changes, an updated notice will be posted and a copy will be made available to you.

Acknowledgement of Receipt of Privacy Practices Notice

This document acknowledges that you have received a copy of the Notice of Privacy practices. This document is not a contract, authorization, release, or consent form. This document will remain in your records.

(Patient) acknowledge that I have received a copy of the notice of privacy practices.