HIPAA NOTICE OF PRIVACY PRACTICES

Your Information. Your Rights. Our 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.

• Our Health Information Privacy Officer is Sophia Ro and you can contact her at:
• (410) 583-5677
• [email protected]

• If using email, PLEASE DO NOT include any health information in the email. Provide enough
  information so that we can identify you and then communicate you through either a secure electronic
  system, or by voice.

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 market our
services.

OUR USES AND DISCLOSURES

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Comply with the law
• 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, 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 review the power of attorney in good faith to determine the person has this
    authority and can act for you before we take any action. We are not liable for fraudulent
    power of attorney forms to the extent we exercise reasonable effort to confirm their
    validity, provided this limitation is subject to any restrictions provided by applicable law.
• 
  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 provided at the top of the Notice of Privacy Practices.
  • 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
    • Share information in another manner specified by you, however, if not expressly
      required by law, we may deny such request, or condition such request on a reasonable
      fee

  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

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.

• 
  To Treat you
  
  • 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.
• 
  To operate 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.
• 
  To bill and collect for our services
  • Example: We give information about you to our billing provider (currently Stripe.com). Our services
    are not currently payable by insurance.

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 occurs that may have compromised the privacy or
  security of your medical 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:

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

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. OUR CHANGE WILL NOT REDUCE YOUR RIGHTS
UNDER
LAW, BUT MAY CLARIFY PROCEDURES, OR REFLECT CHANGES IN APPLICABLE LAW.