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# Notice on Private Practices

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# Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

## YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and 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 other 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 days or your request.

## Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why

## 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 different address.

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<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="2">YOUR RIGHTS (continued)</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Ask us to limit what we use or share</td><td style='text-align: center; word-wrap: break-word;'>• 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 would affect your care.
• We will say “yes” unless a law requires us to share that information.</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Get a list of those with whom we’ve shared information</td><td style='text-align: center; word-wrap: break-word;'>• 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, health care operations and certain other disclosures (such as any you asked us to make).</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Get a copy of this privacy notice</td><td style='text-align: center; word-wrap: break-word;'>• 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</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Choose someone to act for you</td><td style='text-align: center; word-wrap: break-word;'>• 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 the person has this authority and can</td></tr></table>

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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 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.

## YOUR CHOICES

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.

In these cases, you have both the right and choice to tell us to:

<div style="text-align: center;">In these cases, we never share your information unless you give us written permission</div>


- Share information with your family, close friends or others involved in your care.

- Share information in a disaster relief situation.

If you are not able to tell us your preference, for example, if you are unconscious, 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.

Marketing purposes

• Sale of your information

Most sharing of psychotherapy notes

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## OUR USES AND DISCLOSURES (continued)

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care.



We can send you appointment reminders.

Example: We use health information about you to manage your treatment and services.

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:



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

If you are suicidal or a danger to yourself

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<div style="text-align: center;">OUR USES AND DISCLOSURES (continued)</div>


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## OUR RESPONSIBILITIES* We are required by law to maintain the privacy and security of your protected health information.

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 your mind.

For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticeep.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 about you. The new notice will be available upon request, in our office, and on our website.

Effective Date of Notice: May 31, 2018

Privacy Official: Samantha Todd, APRN

Kentucky State University

400 East Main St.

Frankfort, KY 40601

E-mail: Samantha.Todd@kysu.edu

Telephone: (502) 597-6271