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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. Please review it carefully.

Effective date: [DATE] · Last revised: [DATE]

Our commitment to your privacy

Harbor Family Medicine is required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. "Protected health information" means information that identifies you and relates to your past, present or future health, the care we provide, or payment for that care.

How we may use and share your health information

We typically use or share your information in the following ways without needing your written permission.

To treat you

We use your information to provide and coordinate your care, and share it with other professionals who are treating you, such as a specialist we refer you to, a hospital, a pharmacy or a laboratory.

To run our practice

We use and share your information to operate the practice, improve care, train staff, and contact you about appointments, test results and treatment options. We may leave a brief reminder by phone, text or voicemail unless you ask us not to.

To bill for your services

We use and share your information to bill and collect payment from you, your health plan or another responsible party, including checking whether a service is covered.

Other permitted uses

  • Public health and safety: reporting disease, preventing a serious threat to health or safety, reporting suspected abuse or neglect, and product recalls.
  • When required by law, including responding to a court order, subpoena, or a request from a health oversight agency.
  • Research, when a review board has approved the study or the information has been de-identified.
  • Organ and tissue donation, medical examiners and funeral directors.
  • Workers' compensation, law enforcement, and specialized government functions such as military or national security.
  • With family or friends involved in your care, or in a disaster relief situation, unless you object.
  • With business associates who perform services for us, such as billing or IT support, under contracts that require them to protect your information.

Uses that require your written authorization

We will not use or share your information for the following without your written permission, and you may revoke that permission at any time in writing:

  • Marketing communications.
  • Sale of your information.
  • Most sharing of psychotherapy notes.
  • Any other purpose not described in this notice.

Some information, such as mental health, substance use treatment and HIV-related records, has additional protection under state law, and we will follow the stricter rule.

Your rights

When it comes to your health information, you have the following rights. To exercise any of them, contact our Privacy Officer using the details at the end of this notice.

  • Get a copy of your record. Ask to see or get an electronic or paper copy. We will provide it, usually within 30 days, and may charge a reasonable cost-based fee.
  • Ask us to correct your record. If you think something is incorrect or incomplete, you may request a correction. We may say no, but will tell you why in writing within 60 days.
  • Request confidential communications. Ask us to contact you in a specific way, for example only by mail or at a particular number. We will say yes to all reasonable requests.
  • Ask us to limit what we use or share. We are not required to agree, and may say no if it would affect your care. If you pay for a service in full out of pocket, you can ask us not to share that information with your health plan, and we will agree unless the law requires us to share it.
  • Get a list of those with whom we've shared information. Ask for an accounting of disclosures for the six years before your request. We will include all disclosures except those about treatment, payment and operations, and certain others. One list per year is free.
  • Get a copy of this notice. Ask for a paper copy at any time, even if you agreed to receive it electronically.
  • Choose someone to act for you. A person with medical power of attorney or legal guardianship can exercise your rights and make choices about your information.
  • Be notified of a breach. We will let you know promptly if a breach may have compromised the privacy or security of your information.
  • File a complaint. You can complain to us or to the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Our responsibilities

  • We are required by law to maintain the privacy and security of your protected health 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.
  • We will tell you promptly if a breach occurs that may have compromised your information.

Website and online privacy

Our website collects limited technical information, such as pages visited and browser type, to keep the site working and understand how it is used. Forms on this site send the details you enter to our office over an encrypted connection. The contact form is not intended for health information; please use the patient portal for anything medical. We do not sell website visitor information. Third-party services used on this site, such as maps or analytics, have their own privacy policies.

The patient portal is operated by [PORTAL VENDOR] under a business associate agreement and has its own terms of use, which you accept when you create an account.

Changes to this notice

We may change the terms of this notice, and the changes will apply to all information we have about you. The current notice is always available on this page and at our front desk, and will show its effective date at the top.

Questions and complaints

If you have questions about this notice or believe your privacy rights have been violated, contact our Privacy Officer:

[PRIVACY OFFICER NAME], Privacy Officer
Harbor Family Medicine, [STREET ADDRESS], [CITY, STATE ZIP]
Phone [PHONE NUMBER] · Email [PRIVACY EMAIL]

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/, calling 1-877-696-6775, or writing to 200 Independence Avenue, S.W., Washington, D.C. 20201.