Effective date: [ date ]
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.
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. You may change your mind at any time by letting us know in writing.
How we typically use and share your health information
- Treatment. We use your information and share it with other professionals who are treating you.
- Payment. We use and share your information to bill and get payment from health plans or other entities.
- Health care operations. We use and share your information to run our practice, improve your care, and contact you when necessary.
Other ways we may use or share your information
We are allowed or required to share your information in other ways, usually in ways that contribute to the public good. We have to meet many conditions in the law before we can share your information for these purposes:
- When required by federal, state, or local law
- To prevent or reduce a serious threat to anyone's health or safety
- To report suspected abuse, neglect, or domestic violence
- For public health and safety activities
- For health oversight activities authorized by law
- In response to a court or administrative order, or a lawful subpoena
- For workers' compensation claims, law enforcement purposes, and specialized government functions such as military and national security
- To coroners, medical examiners, or funeral directors
Uses that require your written permission
- Most sharing of psychotherapy notes
- Marketing purposes
- Sale of your information
[ If Cedar 7 Wellness maintains substance use disorder treatment records covered by 42 CFR Part 2, insert the required Part 2 language here. Add any additional Utah-specific requirements. ]
Your rights
- Get a copy of your health record. You can ask to see or get an electronic or paper copy of your record. We will provide a copy or a summary, usually within 30 days, and may charge a reasonable, cost-based fee.
- Ask us to correct your record. You can ask us to correct information you think is incorrect or incomplete. We may say no, 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 or at a different address. We will say yes to all reasonable requests.
- Ask us to limit what we use or share. We are not required to agree, but if you pay for a service out of pocket in full, you can ask us not to share that information with your health insurer, and we will say yes unless a law requires us to share it.
- Get a list of those we've shared information with. You can ask for a list of the times we've shared your information for six years prior to the date you ask.
- Get a copy of this notice. You can ask for a paper copy at any time.
- Choose someone to act for you. If someone is your legal guardian or has medical power of attorney, that person can exercise your rights.
File a complaint
If you feel your rights have been violated, you can contact our Privacy Officer using the information below. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at www.hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.
Changes to 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 on request, in our office, and on this website.
Contact
Privacy Officer
[ Name ]
Cedar 7 Wellness, American Fork, Utah
Phone: (385) 406-6515
Email: [ email ]