Health For Life Clinic, Inc. Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Federal law requires us to maintain the privacy of your health information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept confidential. HIPAA gives you, the client, new rights to understand and control how your health information is used. That law also requires us to give you this explanation of how we maintain the privacy of your health information. We reserve the right to change our privacy practices, provided the changes conform to applicable laws. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available on request.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, health care operations, health care reminders, and for public benefit. Any other disclosure requires your written authorization.
• Treatment: providing or managing health care and related services by Dr. Lee.
• Payment: billing or collection activities.
• Health care operations: running the clinic.
• Reminders: appointment reminders or to inform you of changes in the hours by such means as postcards, voicemail messages or letters.
• Public benefit: to report abuse, neglect or domestic violence; by court order, and if required by state and federal laws.

We may create and distribute de-identified health information by removing all references to identifiable information.
Any other uses and disclosures will be made only with YOUR WRITTEN AUTHORIZATION. You must give such authorization in writing to disclose it for any purpose, including but not limited to having a copy sent to another physician or receiving a copy for your own personal use. You may revoke such authorization in writing and we are required to honor that written request unless we have already taken actions relying on your authorization.

You have the following rights, which you can exercise with a written request to the office.
• The right to request restrictions on certain uses and disclosures of protected health information, including those related disclosures to family members, relatives, close personal friends or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information. You must make a request in writing to obtain access to your health information. If you request copies, we will charge you a reasonable cost-based fee that may include labor, copying costs and postage. If you prefer, we may (but are not required to) prepare a summary or explanation of your health information for a fee.
• The right to amend your protected health information. Your request must be in writing and must include an explanation why we should amend your records. We may deny your request under certain circumstances.
• The right to receive an accounting of disclosures of your protected health information.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices. You have recourse if you feel your privacy protections have been violated by a written complaint to the US Department of Health and Human Services about violations of this notice.

I have read and understand the above-stated information.
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