Notice of Privacy Practices

On behalf of itself and all Managed Facilities and Entities


Effective Date: September 11, 2023


Understanding Your Medical Health Record Information

Each time you visit a hospital, physician, nursing home, or other health care provider, the health care provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your medical record, serves as a:

  • Basis for planning your care and treatment.
  • Means of communication among the many health professionals who contribute to your care.
  • Legal document describing the care you received.
  • Means by which you or a third-party payer can verify that you actually received the services billed for.
  • A tool in medical education.
  • A source of information for public health officials charged with improving the health of the regions they serve.
  • A tool to assess the appropriateness and quality of care you received.
  • A tool to improve the quality of healthcare and achieve better patient outcomes.

Understanding what is in your health records and how your health information is used helps you to:

  • Ensure its accuracy and completeness.
  • Understand who, what, where, why and how others may access your health information.
  • Make informed decision about authorizing disclosure to others.
  • Better understand the health information rights detailed below.

Your Rights Under the Federal Privacy Standards

Although your health records are the physical property of the health care provider who completed them, you have certain rights with regard to the information contained therein. You have the right to:

  • Request restrictions on uses and disclosures of your health information for treatment, payment, and health care operations. Health care operations consist of activities that are necessary to carry out the operations of the health care provider, such as quality assurance and peer review. The right to request restrictions does not extend to uses or disclosures permitted or required under 45 CFR 164.502(a)(2)(i) (disclosures to you), 45 CFR 164.510(a) (for facility directories, but note that you have the right to object to such uses), or 45 CFR 164.512 (uses and disclosures not requiring a consent or an authorization). The latter uses and disclosures include, for example, those required by law, like mandatory communicable disease reporting. In those cases, you do not have a right to request restrictions. Even in those cases in which you do have the right to request restrictions, we do not have to agree to the restrictions, other than with respect to fundraising activities, as set forth below, and with respect to disclosures to your insurance company or health plan for treatment services you have paid for in full, unless prohibited by law. If we do agree, however, we will adhere to such restrictions unless you request otherwise or we give you advance notice.
  • You may also ask us to communicate with you by alternate means and, if the method of communication is reasonable, we must grant the alternate communication request.
  • Receive and keep a copy of this Notice of Privacy Practices. Although we have posted a copy in prominent locations throughout the facility and on our website, if you access those copies, you nonetheless have a right to a hard copy on request. The law requires us to ask you to acknowledge receipt of your copy.
  • Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
    • Psychotherapy notes. Such notes comprise those that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record.
    • Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
    • Any of your health information that is subject to the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. 263a, to the extent that the provision of access would be prohibited by law.
    • Information that was obtained from someone other than a health care provider under a promise of confidentiality and when the access requested would be reasonably likely to reveal the source of the information.
  • In other situations, we may deny you access but, if we do, we must provide you with a review of the decision denying access. These reviewable grounds for denial include:
    • When a licensed healthcare professional has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of you or another person.
    • When the protected health information makes reference to another person (other than a health care provider) and a licensed healthcare provider has determined, in the exercise of professional judgment, that the access is reasonably likely to cause substantial harm to such other person.
    • The request is made by your personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to you or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying access within 15 days. If we deny you access, we will explain why and what your rights are, including how to seek review.

If we grant access, we will tell you what, if anything, you have to do to get access. We reserve the right to charge a reasonable, cost-based fee for making copies.

  • Request amendment/correction of your health information. We do not have to grant the request if: We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not.