Effective date: [effective date]
Your rights
You have the right to:
- Get an electronic or paper copy of your medical record. We usually provide it within 30 days. We may charge a reasonable, cost-based fee.
- Ask us to correct your medical record if you think it is wrong or incomplete. We may say no, but we will tell you why in writing within 60 days.
- Ask us to contact you in a specific way (for example, a different phone) or at a different address. We will say yes to all reasonable requests.
- Ask us to limit what we use or share. We are not required to agree, except that if you pay for a service in full out of pocket, you can ask us not to share it with your health insurer.
- Get a list of those we shared your information with, for six years before the date you ask, with some exceptions.
- Get a paper copy of this notice at any time.
- Choose someone to act for you, such as a medical power of attorney or legal guardian.
- File a complaint if you feel your rights are violated. Contact us below, or the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue SW, Washington, D.C. 20201, 1-877-696-6775, or hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.
Your choices
You can tell us whether to share information with family or close friends involved in your care. If you cannot tell us (for example, if you are unconscious), we may share it if we believe it is in your best interest. We never share your information for marketing or sell it unless you give us written permission.
How we use and share your information
- Treatment. We use your information and share it with other professionals who are treating you.
- Running our organization. We use your information to run our practice, improve your care, and contact you when needed.
- Billing. We use and share your information to bill and get payment.
We may also share your information when the law allows or requires it: for public health and safety, health research, to comply with the law, for organ and tissue donation, to work with a medical examiner or funeral director, for workers’ compensation, law enforcement and other government requests, and to respond to lawsuits and legal actions.
Some state laws give more protection to certain information, such as mental health, substance use and reproductive health information. We follow the stricter law.
Our responsibilities
- The law requires us to keep your protected health information private and secure.
- We will tell you promptly if a breach occurs that may have compromised your information.
- We must follow the duties and privacy practices 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. You may change your mind at any time in writing.
Changes to this notice
We can change this notice, and the changes will apply to all information we have about you. The new notice will be on this website and available on request.
Contact
Privacy Officer: [name]. Text or call 385-300-1821, or email [privacy contact email]. Mail: [Modwella legal name and mailing address].