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Notice of Privacy Practices

Step 4

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.

A written record of every visit will be kept in your file. This record contains identifying information about you, your diagnosis, and clinical assessments

Your rights under the Federal Privacy Standards include, but are not limited to the following:

  • You may request restriction on uses and disclosures of your health information for treatment, payment, and health care operations
  • You may receive a copy of this information statement.
  • You may request that communication with you be made by alternative means. I will make every effort to honor reasonable requests.
  • You may request a copy of your file. This will be arranged unless I feel it would cause harm to you or others if that request were approved. If this circumstance should arise, I will review your file with you.
  • I will notify you of individuals who have been given access to your information based on your written release.

The practice:

  • Will keep all of your information private. Reasonable environmental and administrative safeguards are in place to meet this objective.
  • I will attempt to mitigate any breach of your privacy and confidentiality to the best of my ability.

The effective data of this notice is May 31, 2013

Step 5

Next: Privacy Practices Receipt

Fill Out Form #5

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