Physician Referral Form
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Privacy Policy

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 under the Federal Privacy Standard

Although your health records are the physical property of the healthcare provider who completed them, you have the following rights about the information contained therein:

  • Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations.
  • Request that we communicate with you by alternate means or at alternate locations (for example, at your place of work instead of home). If the method of communication is reasonable, we must grant the alternate communication request.
  • Obtain a copy of this notice of privacy practices.
  • We will inspect and copy your health information upon request. However, this right is not absolute. We can deny access in certain situations, such as if access would cause harm. We reserve the right to charge a reasonable, cost-based fee for making copies.
  • Request amendment/correction of your health information. However, under certain circumstances, we may deny your request.
  • Obtain an accounting of uses and disclosures of your health information, except for the uses for treatment, payment, and health care operations.
  • Revoke your authorization to use or disclose health information except to the extent that we have taken action based on the authorization.

Our Responsibilities under the Federal Privacy Standard

In addition to providing you with your rights, as detailed above, the federal privacy standard requires us to take the following measures:

  • Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
  • Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.
  • Abide by the terms of this notice.
  • Train our personnel concerning privacy and confidentiality.
  • Implement a sanction policy to discipline those who breach privacy/ confidentiality or our policies with regard thereto.
  • Mitigate (lessen the harm of) any breach of privacy/confidentiality.
  • We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.

Examples of Disclosures for Treatment, Payment, and Health Operations

  • We will use or disclose your health information for treatment.
  • We will use or disclose your health information for payment.
  • We will use or disclose your health information for health operations.
  • We may provide your health information to business associates as required for treatment, payment, health care operations, or as otherwise required by law: We provide some services through contracts with business associates.

Examples of Other Uses and Disclosures without Authorization: We may use your health information for our facility directory.

  • We may use your health information for notification purposes.
  • We may use or disclose your health information to communicate with your family.
  • We may use or disclose your health information for research.
  • We may disclose your health information to funeral directors.
  • We may use your health information for continuity of care.
  • We may disclose your health information as required by law:

Food and Drug Administration (“FDA”): We may disclose to the FDA health information relative to adverse effects/events concerning food, drugs, supplements, product or product defects, or postmarketing surveillance information to enable product recalls, repairs, or replacement.

Workers’ compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law.

Public health: As law requires, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional institution: If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid court order or subpoena. Such information will be limited to that allowed under applicable federal and state laws.

Health oversight agencies and public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.

The United States Department of Health and Human Services (“DHHS”): Under the privacy standards, we must disclose your health information to DHHS as necessary to determine our compliance with those standards.

Other use or disclosure of your health information requires an authorization signed by you or your personal representative. You may revoke an authorization by notifying us in writing of the revocation.

How to Get More Information or to Report a Problem

Suppose you believe your privacy rights have been violated. In that case, you may file a complaint with our facility by contacting or office, or with, the Secretary for the Department of Health and Human Services. We will not retaliate against you if you file a complaint.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF WE CHANGE OUR INFORMATION PRACTICES, WE WILL MAIL A REVISED NOTICE TO THE ADDRESS YOU GIVEN US.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF WE CHANGE OUR INFORMATION PRACTICES, WE WILL MAIL A REVISED NOTICE TO THE ADDRESS YOU GIVEN US.