Privacy Officer Name and Contact Information: Eliza Giard, Executive Director

Effective Date of Notice: September 15, 2025

 

Your Information. Your Rights. Our Responsibilities.

 

This notice describes how medical information about you may be used and disclosed and how you

can access this information. Please review it carefully.

 

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record.

• Correct 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.

 

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition.

• Provide disaster relief.

• Include you in a hospital directory.

• Provide mental health care.

• Market our services and sell your information.

• Raise funds.

 

Our Uses and Disclosures

We may use and share your information as we:

• Treat you.

• Run our organization.

• 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

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, by 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.

 

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 before the date you ask, who we shared it with, and why.

• We will include all the disclosures except those about treatment, payment, 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 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 using the

information on page 1.•

•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,

calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

 

Your Choices

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.

• Include your information in a hospital directory.

 

If you cannot 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

 

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

• Treat you.

We can use your health information and share it with other professionals 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.

 

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 must meet many conditions

in the law before we can share your information for these purposes. For more information, see

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/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

 

Do research: 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 comply with

federal privacy law.

 

Respond to organ and tissue donation requests: We can share your health information 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.

 

Our Responsibilities

 

• 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 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.

• 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 anytime. Let us know in writing if you change your mind.

 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

 

Changes to the Terms of this Notice

We can change the terms of this notice, which will apply to all information we have about you. The

new notice will be available upon request in our office and on our website.