NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. ELECTRONIC COPY
AVAILABLE UPON REQUEST.
State and Federal laws require us to maintain the privacy of your health information and to inform you about
our privacy practices by providing you with this Notice. We must follow the privacy practices as described
below. This Notice will take effect on May 20, 2021 and will remain in effect until it is amended or replaced by
It is our right to change our privacy practices provided law permits the changes. Before we make a significant
change, this Notice will be amended to reflect the changes and we will make the new Notice available upon
request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice
effective for all health information maintained, created, and/or received by us before the date changes were
You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Ty Houston.
Information on contacting us can be found at the end of this Notice.
TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION
We will keep your health information confidential, using it only for the following purposes:
Treatment: We may use your health information to provide you with our professional services. We have
established “minimum necessary or need to know” standards that limit various staff members’ access to your
health information per their primary job functions. Everyone on our staff is required to sign a confidentiality
Disclosure: We may disclose and/or share your healthcare information with other health care professionals
who provide treatment and/or service to you either by fax or electronically through electronic medical
records. These professionals will have a privacy and confidentiality policy like this one. Health information
about you may also be disclosed to your family, friends, and/or other persons you choose to involve in your
care, only if you agree that we may do so. The uses and disclosures that constitute the sale of Personal Health
Information and other uses and disclosures not described in the notice will be made only with authorization
from the individual.
Payment: We may use and disclose your health information to seek payment for services we provide to you.
This disclosure involves our business office staff and may include insurance organizations or other businesses
that may become involved in the process of mailing statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family
member or anyone responsible for your care, in case of any emergency involving your care, your location, your
general condition, or death. If possible we will provide you with an opportunity to object to this use or
disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to
disclose only that information directly relevant to your care. We will also use our professional judgment to
make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or
other similar forms of health information and/or supplies unless you have advised us otherwise.
Healthcare Operations: We will use and disclose your health information to keep our practice operable.
Examples of personnel who may have access to this information include, but are not limited to, our medical
records staff, outside health or management reviewers and individuals performing similar activities.
Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.
Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.
National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence, or other national security activities, we may disclose it to authorized federal officials.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards, or letters.
PATIENT PRIVACY RIGHTS AS OUR PATIENT
Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter. Once approved, an appointment can be made to review your records. Medical records can also be requested online at https://www.swellbox.com/wellstreet-wizard.html.
Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment, or healthcare operations. You can request non-routine disclosures going back 6 years prior to the date of your request.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing.
Breach: An individual has the right to notice in the event of a breach. If a breach does occur, our privacy officer will contact you directly to inform you.
Access to Care: You have the right to access, and request for, and an amendment of your medical records.
Safety: You have a right to receive safe, high quality care.
Respect: You have a right to be shown respect, dignity, and consideration regarding your healthcare.
Communication: You have a right to be informed about services, treatment options, and costs in a clear and susceptible way.
Participation: You have a right to be included in decisions and choices regarding your care.
Privacy: You have a right to privacy and confidentiality of your personal information.
Comment: You have a right to comment on your care and to have your concerns addressed.
Health Records: You have the right to refuse the release of your personal health information (except when permitted by law).
Interpreter: You have the right to have clinic personnel or a language line available for patient/family members with a language barrier.
PATIENT RESPONSIBILITIES AS OUR PATIENT
Advance Care Directive / Power of Attorney / Guardianship: Please inform your health care professional if you have a current Advance Care Directive or Power of Attorney for any health or personal matters, or if you are subject to a guardianship order.
Safety: Tell us your safety concerns.
Respect: Consider the wellbeing and rights of others.
Communication: Provide information regarding your medical history and ask questions.
Participation: Follow your treatment plan, cooperate, and participate where able.
Services: You have the right to refuse care or services.
Complaints / Feedback: You should direct any complaint to a staff member or member of management so that immediate and appropriate action can be taken to remedy your concern.
QUESTIONS AND COMPLAINTS
You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer or Security Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision, we made regarding your access to your health information, you can complain to us. In writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. The toll-free number for the U.S. Department of Health and Human Services at 1-877-696-6775.
HOW TO CONTACT US
HIPAA Notice of Privacy Practices
This form does not constitute legal advice and covers only federal, not state, law.