3′ x 4′ Full-Color Motivational Banner for HIPAA Notice of Privacy Act
HIPAA HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
Rights to Request Restrictions:The provider may use and may disclose your personal health information for treatment, such as treatment of physical or mental impairments, and for the billing of such services. Additionally, providers may create, obtain, and disclose PHI for health care operations and may use such information for accreditation purposes.
These include use and disclosure:
• when required by law
• about decedents• for public health activities
• for law enforcement
• for judicial & administrative proceedings
• for victims of abuse, neglect, or domestic violence
• for cadaveric organ, eye, or tissue donation purposes
• for specialized government functions
• to avert a serious threat to health or safety
• for health oversight activities• for worker’s compensation
• for research and soliciting funds
• for appointment reminders
• to notify you of treatment alternatives
Rights to Amend Your Personal Health Information:If you believe that your PHI is incorrect or that an important part of it is missing, you have the right to ask to have your provider amend your PHI while it is kept by or for this provider. You must provide your request and your reason for the request in writing. The provider may deny your request if it is not in writing or does not include a reason that supports the request. In addition, the provider may deny your request if you ask them to amend PHI that:(1) is accurate and complete;(2) was not created by them, unless the person or provider that created the PHI is no longer available to make the amendment;(3) is not part of the PHI kept by or for them; or(4) is not part of the PHI which you would be permitted to inspect and copy.
Rights to Inspect and Copy Your Personal Health Information:You may inspect and copy your PHI that is maintained in accordance with HIPAA privacy regulations. These requests must be made in writing to the Privacy Officer.Rights to a List of Disclosures:You have the right to an accounting of disclosures of PHI. Requests for this accounting must be made in writing to the Privacy Officer.
Rights to Request Amendments:If you feel that your Health Information is incorrect or incomplete, you may ask your provider to amend the information and you must tell them the reason for your request. You have the right to request an amendment for as long as the information is kept by or for the provider. A request for amendments must be submitted, in writing, to the Privacy Officer.
Changes to this Notice:We reserve the right to change the terms of this Notice. In that event this provider will make the revised notice applicable to all health records, regardless of whether the records were created before or after the revision to the Notice. The provider will make the changes available to our customers upon request.
Complaints:If you believe your privacy rights have been violated in any way, you may file a complaint in writing with our HIPAA Privacy Contact Person. We will attempt to resolve your complaint promptly. Alternatively, you may complain to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Washington, D.C. 20201, generally within 180 days of when the act or omission complained of occurred.If you have any questions or concerns regarding your protected health information, please ask to speak with this facility’s Privacy Officer.