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 for printed materials. In some limited circumstances, we may say
“no” to your request, and you can ask that the denial be reviewed.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Your
request should be in writing and include the reasons for the request for amendment.
To inquire on how to do this, please call us at 1-855-769-6337
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
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.” For example, we may refuse your request
for a restriction 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), except if required by regulation. 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 make sure that the person has this authority and can act for you before we take any action.
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 on page 1.
You can file a complaint with the Secretary of 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.
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 if
feasible or required by law.
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
Include your information in a facility directory
If you are not able to tell us your preference, for example if you are unconscious or unavailable, 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. We may share certain information
after you have died.
In these cases, unless allowed by law, we do not share your information unless you give us written
Marketing purposes (except as described below)
Sale of your information
Most sharing of psychotherapy notes
In the case of fund raising
We may contact you and use certain information about you for fundraising efforts, but you can tell us not
to do so. We may use a business associate or institutionally related foundation for these contacts.
How do we typically use or share your health
information? We typically use or share your health information in the following ways.
We can use your health information and share it, electronically or otherwise, with other professionals who
are treating you.
Example: A doctor treating you for an injury asks about your overall
health condition. We may share your information for lawful purposes through electronic health information
Run our organization and engage in other health care operations
We can use and share your health information to run our business, improve your care,and contact you when
necessary. We can also share for other health care operations purposes permitted by law or regulations.
Example: We use health information about you to manage your treatment and
services. We may share health information with other entities for their health care operations and other
Bill for services
To the extent applicable, we can use and share your health information to bill and get payment from health
plans, from you,or from other entities, or to help other entities get payment.
Example: We give information about you to your health insurance plan so
it will pay for your services.
We may give information to entitiesthat help us collect payments. We may share your information
with other entities for their payment purposes.
How else can we use or share your health
information? We are allowed or required to share your information in other ways – usually in ways that
contribute to the public good, such as public health and research. We have to meet many conditions in the law
before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research as permitted by laws and rules.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of
Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations and tissue banks.
Work with a medical examiner or funeral director and share information after death
We can share health information with a coroner, medical examiner, or funeral director when an individual
We may share your information after your death to the extent permitted by federal HIPAA rules
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond and participate in lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response
to a subpoena. We can also share information when a protective order is in place.
Other uses and disclosures
Business Associates - There are some health-related services provided through contracts with third
parties, called “business associates,” that may need the information to perform certain services on our behalf.
Examples include software or technology vendors we may utilize to provide technical support, attorneys providing
legal services to us, accountants, consultants, billing and collection companies, and others. When such a
service is contracted, we may share your protected health information with such business associates and may
allow our business associates to create, receive, maintain, disclose, or transmit your information on our behalf
in order for the business associate to provide services to us, or for the proper management and administration
of the business associate or to enable the business associate to fulfill its legal responsibilities. Business
associates must protect any health information they receive from, or create and maintain on our behalf. In
addition, business associates may re-disclose your health information for their own proper management and
administration, to fulfill their legal responsibilities, and to business associates that are subcontractors in
order for the subcontractors to provide services to the business associate. The subcontractors will be subject
to the same restrictions and conditions that apply to the business associate. Whenever such an arrangement
involves the use or disclosure of your information to our business associate, we will have a written contract
with our business associate that contains terms designed to protect the privacy of your information.
De-identified information - We may use and disclose your health information to create de-identified
information or limited data sets, and may use and disclose such information as permitted by law.
Inmates - If you are an inmate of a correctional institution or under the custody of a law enforcement
official, we may release information about you to the correctional institution or law enforcement official as
permitted by applicable laws and rules.
Marketing – We may use and disclose your protected health information to communicate face-to-face with
you to encourage you to purchase or use a product or service, or to provide a promotional gift of nominal value
to you. We may also contact you about treatment alternatives or other health-related benefits and services that
may be useful to you.
Privacy and Security
We are required by law to maintain the privacy and security of your protected health information.
While we take privacy and security very seriously, sometimes things go wrong. We will let you know
promptly if a breach occurs that may have compromised the privacy or security of your 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
We will comply with state law. We will obtain your written consent for certain disclosures if your consent
is required under state law.
We may ask you for consent to share certain medical information. This consent is required by state law for
some disclosures and allows us to be certain that we can share your medical information for all of the
reasons explained in this notice. For example, we will ask for your consent to share your information for
payment purposes. We may also ask for your consent to share certain sensitive information that may have
extra protection under state or federal laws. For example, we may ask for your written authorization to
disclose information we receive from certain substance abuse facilities.
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 website.
Effective date: August 25, 2020
This Notice of Privacy Practices applies to the following organization:
Give Back Enterprises, LLC (“givebackRx”)
1155 15th Street NW, Suite 720, Washington, DC 20005