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Notice of Privacy Practices


POLICY: Notice of Privacy Practices

DATE OF ISSUE: August 9, 2013
REVISED DATE: August 9, 2013

An individual has the right to adequate notice of uses and disclosures of PHI that Company may make and of the individual’s rights and Company’s duties with respect to the PHI. Generally, a covered entity must provide an individual with its Notice of Privacy Practices (its “Notice”) that describes the covered entity’s uses and disclosures of PHI.

The Company will develop and adhere to its Notice of Privacy Practices (the “Notice”) or that of any direct treatment provider that provides such a Notice on Company’s behalf. The Privacy Officer shall be responsible for developing and maintaining the Company’s Notice. The Notice currently adopted by the Company is attached as Attachment A. Company may not use or disclose PHI in a manner inconsistent with its Notice or that of any direct treatment provider that provides such a Notice on Company’s behalf.

The Privacy Officer will be listed on the Notice and serve as the contact person for individuals who have complaints about how the Company has used or disclosed their PHI or who have questions about the Company’s Notice.

Copies of the Company’s Notice will be provided to individuals, including members of the public, upon request. The Company will use reasonable efforts to obtain the patient’s acknowledgment of receipt of the Notice, and such acknowledgment may be in the form of the patient’s initials on a cover sheet or the patient’s signature on a list or other form. The acknowledgment may also be electronic. If Company is unable to obtain a patient’s acknowledgement of receipt of the Notice, Company shall still be required to provide the patient with access to his or her PHI if requested as set forth in these Policies and Procedures.

The Notice will be promptly revised whenever there is a material change to the Company’s practices described in the Notice. A covered entity may not apply a revision to information received or maintained prior to the revision unless it has reserved the right to do so in its Notice. Unless required by law, material revisions will not be implemented prior to the effective date of the revised Notice. Revised Notices will be made available upon request.

The Company’s Notice will be retained for six (6) years from its last effective date. The Company will likewise retain acknowledgements (or adequate documentation of good faith efforts to obtain written acknowledgements) for a duration of six (6) years.


Effective Date: AUGUST 9, 2013

Patients have the right to view, inspect and receive copies of their protected health information, including their medical record. You will not be charged to view and inspect your medical record, but we may charge a fee for copying your medical record. If you would like your record copied, whether in paper or electronic form, you must agree in advance to the copying charge. In certain circumstances, we may deny access to your medical record. If so, we will notify you of our denial in writing and we will explain to you why your request to view or copy your medical record was denied. In certain circumstances, you may ask for an appeal to have our denial reviewed by another health care professional.

If we deny your request to review your medical record, you may ask for an appeal if our denial is for the following reasons:

  • We have determined that access to the record would endanger the life or physical safety of you or another person.
  • We have determined that the medical record makes reference to another person and that access to the record may cause substantial harm to that person.
  • The request for access to the medical record was made by your personal representative and we have determined that access to the record could cause harm to you or to another person.
  • If we deny your request for certain other reasons, you are not entitled to an appeal. These reasons are:

    • The requested record is not part of a designated record set.
    • The requested record contains psychotherapy notes.
    • The requested record was put together in reasonable anticipation of or for use in a civil, criminal, or administrative action or proceeding.
    • The requested record is subject to the Clinical Laboratory Improvements Amendments or the federal Privacy Act and access is prohibited by those laws.
    • The requested record is about an inmate in a correctional facility.
    • The requested record is being used in a research study and you were advised prior to agreeing to participate in the study that access to your PHI would be prohibited during the study.
    • The requested record was obtained from someone other than a health care provider and access to the record would violate a promise of confidentiality that was made to the person or organization that provided the information.

    Patients who wish to inspect their medical records must make a written request. (Download the Medical Records Request Form below). The request must be submitted to us no longer than sixty (60) days after the request is signed. We will usually respond to your request within thirty (30) days after receiving it. But we are permitted to have one thirty (30) day extension of the above time to consider your request, as long as we inform you of the need and the reason for the extension.

    Download Medical Records Request Form