HIPAA Notice of Privacy Practices

Our duties

Arizona Trim Clinic is required by law to maintain the privacy of your protected health information (PHI), to give you this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you if a breach of your unsecured PHI occurs.

How we may use and share your health information

• Treatment: to provide and coordinate your care, including with pharmacies, labs, and other providers involved in your care.
• Payment: to bill and collect payment for services, including from health plans if applicable.
• Health care operations: to run our clinic, improve quality, train staff, and contact you about appointments and treatment.
• Business associates: with vendors that perform services for us, such as our electronic health record and scheduling platform (Jane App), under written agreements that require them to protect your information.

Other uses and disclosures allowed or required by law

We may share your information without your written authorization when required or permitted by law, including: as required by federal, state, or local law; for public health activities (such as reporting adverse drug reactions); to report abuse, neglect, or domestic violence; for health oversight activities; in response to court orders or other lawful process; for law enforcement purposes; to coroners or medical examiners; to avert a serious threat to health or safety; for workers’ compensation; and for specialized government functions. Arizona law may give additional protections to certain information, which we follow.

Uses that require your written authorization

We will not use or share your information for marketing, sell your information, or share psychotherapy notes without your written authorization. Other uses not described in this notice will be made only with your written authorization, which you may revoke in writing at any time (except to the extent we have already relied on it).

Your rights

• Get a copy of your records: you may request an electronic or paper copy of your medical record. We may charge a reasonable, cost-based fee.
• Ask us to correct your record if you believe it is incorrect or incomplete. We may say no, but we will explain why in writing.
• Request confidential communications, such as contacting you at a different address or phone number.
• Ask us to limit what we use or share. We are not required to agree, except that if you pay for a service in full out of pocket, you may ask us not to share that information with your health plan.
• Get a list of those with whom we’ve shared information (an accounting of disclosures) for the past six years, with certain exceptions.
• Get a copy of this notice at any time, on paper or electronically.
• Choose someone to act for you, such as a legal guardian or person with medical power of attorney.
• File a complaint if you believe your privacy rights have been violated (see below).

Your choices

You may tell us whether to share information with family or friends involved in your care. If you are unable to tell us, we may share information if we believe it is in your best interest.

Complaints

You may file a complaint with our Privacy Officer at 602-769-3801, Trangiabao880@gmail.com, or 3033 W Bell Rd Ste 102, Phoenix, AZ 85053. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.

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 new notice will be available on request, in our office, and on this website.

Privacy Officer

[Name of designated Privacy Officer — client to provide] · Arizona Trim Clinic · 3033 W Bell Rd Ste 102, Phoenix, AZ 85053 · 602-769-3801