Your information. Your rights. Your responsibilities.
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.
Overview of Your Rights
You have the right to:
- Get a copy of your paper or electronic medical record
- Request a correction to your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Overview of Your Choices
You have some choices in the way that we use and share information as we:
- Provide disaster relief
- Provide mental health care
- Market our services and sell your information
- Tell family and friends about your condition
- Raise funds
Overview of Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
Your Rights in Detail
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us at Privacy Officer at Compliance@healthvillepharmacy.com
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices in Detail
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures in Detail
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see: https://www.hhs.gov/hipaa/for-individuals/index.html
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information, see:
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other instructions for this notice
- This notice is effective as of: February 1st, 2023
- If you have questions about these laws, please contact the privacy officer at Compliance@healthvillepharmacy.com
- We never market or sell personal information.
- If one of our providers believes that a patient/client is threatening serious bodily harm to another, the provider is required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient/client.
- If a patient/client presents a serious and credible threat to harm themselves, our providers may be obligated to seek hospitalization for them or to contact family members or others who can help provide protection.
- In most cases, if a patient/client is under the age of 18, our staff must have the consent of the parent/s or guardian/s to provide mental health treatment barring circumstances in which obtaining the guardian’s consent may cause significant harm, in which case we reserve the right to refer to alternative, specialized agencies. In cases which only one parent/guardian has custody or power for medical decision-making, we may need documentation substantiating such. It is the policy of our organization that parents are involved in treatment, with the caveat that an adolescent is able to express what they want this clinician to share. This will not always direct treatment, but it is at the discretion of the provider to keep information confidential with an adolescent to ensure the creation of a safe space for the younger individual and improve their treatment outcomes. However, if there is an immediate safety concern, the parents will be promptly notified.
- If applicable, insurance companies are made aware of diagnoses, visit types, lab results and other clinically necessary information for continued provision of services. Sometimes, insurance companies may contact the patient/client by mail, telephone or other means. In circumstances in which a patient/client is concerned about their confidentiality as it relates to their insurance company, it would be prudent for the patient/client to pay privately and not utilize their insurance benefits.
- If we are contacted by emergency room providers who disclose to us your incapacity or emergency circumstances, we will first reach out to you and your emergency contact on our file to verify the authenticity of such claim. If we are unsuccessful in this outreach, we may disclose protected health information (PHI) to the hospital personnel based on a determination using our professional judgment disclosing only information that is directly relevant to the outside contact’s involvement in your health care. We would not, however, disclose information unrelated to your emergency care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of PHI.
- Appointment reminders: We may use or disclose your name and basic appointment information in providing you with appointment reminders (such as voice mails, e-mails, postcards, SMS messages, or letters) that may reference the practices of medicine or mental health services.