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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY

Your Information. Your Rights. Our Responsibilities.

You have the right to:

Get a copy of your health and claims records

Correct your health and claims records

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we’ve shared your information

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

Choose the way we contact you

You have some choices in the way that we use and share information as we:

 Answer coverage questions from your family and friends

 Provide disaster relief

 Market our services

Our Uses and Disclosures

We may use and share your information as we:

Help manage the health care treatment you receive

Run our organization

Pay for your health services

 Administer your health plan

 Help with public health and safety issues

 Do research

 Comply with the law

 Address workers’ compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Request confidential communications

Ask us to limit what we use or share

Request that we not to use or share certain health information for treatment, payment, or our operations.

Get a list of those with whom we’ve shared information

You can ask for a list of the times we’ve shared your health information, who we shared it with, and why.

 We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

* We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

*We are not required to agree to your request, and we may say “no” if it would affect your care.

File a complaint if you feel your rights are violated

You may do this by asking for Tiffany, Stacie or manager on duty. You may also do so by email at [email protected] or by filling out a complaint form from the front desk and sending it to

ATTN: Stacie Coggon

2211 E. Pecos Road Ste. 1

Chandler, AZ 85225

 All complaints must include the name of the offending person and the acts or omissions believed to be in violation. Complaints must be filed within 180 days of violation.

*We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, let us know.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in payment for your care

Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

Marketing purposes

Our Uses and Disclosures

How do we typically use or share your health information?

Help manage the health care treatment you receive

We can use your health information and share it with professionals who are treating you.

Run our organization

We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

We can use and disclose your health information as we request payment for your health services.

Administer your plan

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease

Helping with product recalls

Reporting adverse reactions to medications

Reporting suspected abuse, neglect, or domestic violence

Preventing or reducing a serious threat to anyone’s health or safety

Do research

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

We can share health information about you with organ procurement organizations.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims

For law enforcement purposes or with a law enforcement official

With health oversight agencies for activities authorized by law

For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

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.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of 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 upon request, on our web site, and we will email a copy to you.

Other Instructions for Notice

Effective Date of this Notice – September 1, 2016

Updated 9/25/2017

Contact Stacie Coggon 480-812-2211 or [email protected]

We do not sell any personal information

You may view your patient information on www.revolutionPHR.com with a username and password we provide for you. If you have not received one you may request one from the front desk.