When it comes to your health information, you have certain rights. This section explains your
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
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
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
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)
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
affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us
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
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
care operations, and certain other disclosures (such as any you asked us to make).
provide one accounting a year for free but will charge a reasonable, cost-based fee
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
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
that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take
- 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
- You can file a complaint with the U.S. Department of Health and Human Services
Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.
calling 1-877-696-6775 FREE, 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
preference for how we share your information in the situations described below, talk to us. Tell
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
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go
share your information if we believe it is in your best interest. We may also share your
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 permission:
- Marketing purposes
- Sale of your information
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 with other professionals who are treating
Example: A doctor treating you for an injury asks another doctor about your overall health
Run our organization
We can use and share your health information to run our practice, improve your care, and contact
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other
Example: We give information about you to your health insurance plan so it will pay for your
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
to the public good, such as public health and research. We have to meet many conditions in
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:
- Preventing disease
- 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
- Do research
- We can use or share your information for health research.
- 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
- Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
- Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when
- 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
- Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or
response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health
- We will let you know promptly if a breach occurs that may have compromised the privacy or
of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy
- We will not use or share your information other than as described here unless you tell us we
writing. If you tell us we can, you may change your mind at any time. Let us know in writing
change your mind.
- For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.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
The new notice will be available upon request, on our web site, and we will mail a copy to you.
This Notice of Privacy applies to all affiliated entities doing business as Far North Surgery
Far North Surgery Centers
Phone : 907-276-3676
Email : firstname.lastname@example.org
Effective Date of this Notice : April 10, 2016