Our Pledge Regarding Medical Information: The privacy of your medical information is important to us. We understand that your “Protected Health Information” (PHI) is personal and we are committed to protecting it. We create a record of care and services you receive at our clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share PHI about you. We also describe your rights and certain duties we have regarding the use and disclosure of PHI.

Our Legal Duty:
The law requires us to
• Keep your PHI private.
• Give you notice describing our legal duties, privacy practices, and your rights regarding your medical information.
• Follow the terms of this Notice that is currently in effect.
• Give you this Notice of our duties and privacy practices with respect to your PHI.

We May Use and Disclose Medical Information About You: The following categories describe different ways we may use and disclose PHI. Not every use or disclosure will be listed.

For Treatment: We may use and disclose your PHI to provide you with medical treatments or services. For example, we may disclose your PHI to doctors, nurses, and other health care personnel to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose your PHI to other people who provide services that are a part of your care, such as a hospice or home care agency.

For Payment: We may use and disclose your PHI to bill and collect payment for your health care services. We may disclose your PHI to other health care providers and organizations involved in your care to assist in their billing and collection efforts. For example, disclosures to your health insurance plan about services we recommend for you so it can determine eligibility, coverage, or medical necessity or for utilization review activities. We may also disclose your PHI to third parties for collection of payment.

For Health Care Operations: We may use and disclose your PHI in the course of operating our clinic. For example, we may call you by name in the waiting area. We may disclose information to doctors, nurses, technicians, training doctors, medical students, and other healthcare personnel for review and learning purposes.

For Appointment Reminders: We may use and disclose your PHI to contact you as a reminder that you have an appointment or to provide you information regarding your medical care.

For Treatment Alternatives: We may use and disclose PHI to tell you about the possible treatment options or alternative.

We May Make These Uses and Disclosures Without Your Authorization

When Required By Law: We will use and disclose your PHI when we are required to do so by federal, state, or local law.

To Avert a Serious Threat to Health of Safety: We may use and disclose your PHI to prevent a serious threat to your health and safety or the health and safety of others.

For Specific Government Functions: We may disclose PHI to military personnel and veterans in certain situations or for national security reasons, such as protection of the President.

For Legal Proceedings: We may disclose your PHI in response to a subpoena or other lawful process by someone involved in a dispute, but only after obtaining an order protecting the PHI requested.

For Health Oversight: We may disclose PHI about you to a state or federal health oversight agency that is authorized by law to oversee our operations. These activities are necessary for the government to monitor our health care system, government programs and compliance with civil rights law.

To Coroners, Medical Examiners, and Funeral Directors: We may disclose your PHI to a coroner or medical examiner. This may be necessary to identify a deceased person or to determine the cause of death. We also may release PHI to funeral directors as necessary for them to carry out their duties.

For Workers’ Compensation: We may disclose your PHI as permitted by workers’ compensation laws and other similar programs.

For Public Health: We will disclose PHI to public health authorities for public health activities, investigations, or interventions as required by law.


You have the right to request restrictions on how we use and disclose your PHI. We, however, are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, your request must be in writing to our Privacy Officer and must describe:
• The information you wish restricted.
• Whether you are requesting to limit our use, disclosures, or both.
• To whom you want the limitation to apply.

You have the right to inspect and obtain a copy of your PHI that our clinic uses to make decisions about you for as long as we maintain the PHI. If you want copies of your PHI, a charge for copying may be assessed to you.

You have the right to request an amendment if you feel that the PHI that we have about you is incorrect or incomplete. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with us. We may prepare a rebuttal and will provide you with a copy of such rebuttal.

You have the right to request a list of disclosures we have made about you, to whom, and why. This applies to disclosures made for reasons other than treatment, payment, or our health care operations. It also excludes disclosures we made to you or as authorized by you, for a facility directory, to family members or friends involved in your care, for notification purposes, or as required by law. The right to receive this information is subject to certain exceptions, restrictions, and limitations.

You have the right to a paper copy of this Notice. You are entitled to receive a paper copy of our Notice. You may ask us to give you a copy of this Notice at any time.

You have the right to file a complaint. If you believe your privacy rights regarding your PHI may have been violated, you may file a complaint with the Secretary fo the Department of Health and Human Services. You will not be penalized for filing a complaint.

For more information, contact our Privacy Officer, Brian Rapoza at (808) 949-0091.

HDRS reserves the right to change the terms of this Notice, and make the new Notice provisions effective for all protected health information that it maintains, at any time.

Click here to download a copy of this notice.