Notice of Privacy Practice

Effective January 2003

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully.

Your Health Information & Rights

Each time you visit a hospital, physician, or other healthcare providers, a record or your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information is referred to as your health or medical record. This Notice of Privacy Practices described how we may use or disclose your health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law.

Although your health record is the property of this practice, the information belongs to you. You have the right to:

  • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
  • Obtain a paper copy of this notice of privacy practices
  • Inspect and request a copy of your medical record as provided for 45 CFR 164.524
  • Amend your health record as provided in 45 CFR 164.526
  • Obtain an accounting of disclosure of your health information as provided in 45 CFR 164.528
  • Request communications of your health information by alternative means and locations

Renew Health and Wellness’s Responsibilities:

  1. Maintain the privacy of your health information
  2. Provide you with this notice as to our legal duties and privacy practices with respect to your health information.
  3. Abide by the terms of this notice
  4. Notify you if we are unable to agree to a requested restriction

We reserve the right to change our privacy practices and to make the new provisions effective for all protected health information we maintain. The current Notice of Privacy Practices can be reviewed by contacting us by calling and requesting that a revised copy be sent to you in the mail. We will not use or disclose your health information without your authorization, except as described in this notice.

For more information or to report a problem

If you have questions and would like additional information, you may contact the Center Manager for our practice. If you believe that your privacy rights have been violated, you can file a complaint with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosure for Treatment, Payment, and Health Care Operations:

Renew Health & Wellness will use your health information for treatment. Your health information may be released to other healthcare professionals within the hospital and the community for the purpose of providing you with quality healthcare. For example: Information obtained by one of our staff including physicians, nurses, and administrative staff will be recorded in your record and used to determine the course of treatment that should work best for you. We will also provide your physician or a subsequent healthcare provider, such as a nursing home, home health care agency, or physical therapy office, with copies of various reports that will assist them in treating outside of this office.

We will use your health information for payment. For example: A bill may be sent to your or a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis procedures, tests, and supplies used in the course of your care in our office. If you understand the above notice and information contained within, we ask that you sign and date that you acknowledge receipt of this information from our office. We will keep a copy of this signed notice in your medical record and provide you a copy for your own records. Thank you.