Rights of the Patient:

• 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 our privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Choices of the Patient:

• How/If we tell family and friends about your condition

• How we provide disaster relief

• As Providers, 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 medical examiners or a funeral director

• Address workers compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

Responsibilities of the Provider:

• We are required by law to maintain the privacy and security of the patient's protected health information

• We will let the patient/legal guardian know promptly if a breach occurs that may have compromised the privacy or security of the patient's protected health information

• We must follow the duties and privacy practices described in the complete notice and give the patient/legal guardian a copy of it at request

• We will not use or share patient information in ways other than as described in the complete notice unless the patient/legal guardian tells us we can in writing. If the patient/legal guardian tells us we can, the patient/legal guardian may change their mind at any time. Let us know in writing should the patient/guardian change their mind. 

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**Again, this is not a binding agreement, nor is it the complete document we use, and our patients agree to in our office. This is a quick summary, meant to provide basic information on this topic.
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