We are required by law to maintain the privacy and security of your PHI, give you this notice of our legal duties and privacy practices regarding health information about you, let you know if a breach occurs that may compromise the privacy or security of your PHI, and follow the terms of our notice that is currently in effect.
The following describes the ways we may use and disclose your PHI. Except for the purposes described below, we will use and/or disclose your PHI only with your written permission. You may revoke such permission at any time by writing to Life Option’s Executive Director.
We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. Your PHI may be shared with outside entities that provide ancillary services to your treatment.
We may use and disclose PHI for health care operations purposes. These uses and disclosures are necessary to ensure that all our patients receive quality care and to operate and manage our office.
We may use and disclose PHI to contact you to remind you that you have an appointment with us, treatment alternatives, or health-related benefits and services that may be of interest to you.
For uses beyond treatment and operation, we will normally seek your authorization before disclosing your PHI. However, disclosure of your PHI may be made without your consent or authorization when required by law, when necessary for public health reasons, when necessary to avoid a threat of harm to you or a third party, or when other circumstances may reasonably require or justify such disclosure.
You have the following rights regarding PHI we have about you.
You have the right to inspect and copy PHI that may be used to make decisions about your care. You will be permitted to inspect your PHI upon written request. We will respond to your request within 30 days. If we deny your access request, we will give you written reasons for the denial. If you would like copies of your PHI, we will make reasonable efforts to grant your request. You will be able to designate selected parts of your PHI to be copied.
If you feel that the PHI we have is incorrect or incomplete, you have the right to ask us to amend the information. To request an amendment, you must make your request, in writing, to Life Options.
You have the right to choose how we contact you. You may request that we send information to an alternative address or by alternative means. We will accept your request if it is reasonably easy for us to do so.
You have the right to request a list of certain disclosures that were made for purposes other than treatment and health care operations or for which you provided written authorization. This request must be made in writing to Life Options.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you by mail or at work.
You have the right to request a restriction or limitation on the PHI we use or disclose for treatment or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse.
You have the right to revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred before the date on which your revocation of consent is received will not be affected.
We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future. We will have a copy of our current notice available at the front desk of each office. The notice will contain the effective date on the top of the first page.
If you have any questions or concerns about this notice, please contact our Executive Director at 509-882-1899.
Signature:
I have reviewed this consent form and give my permission to Life Options to use and disclose my health information following the Notice of Privacy Practices.
Date: _______________________________
Printed Name of Client: ____________________________________________________
Signature of Client: ________________________________________________________
*Please file this form in client’s medical record.
