(On Pregnancy Center Letterhead)

PRIVACY PRACTICES DISCLOSURE

Privacy Officer Name and Contact Information:

Last Updated:

Your Information

This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.  Your information is referred to as Personally Identifiable Health Information (PIHI). 

Our Commitment to You

We commit to treat you with kindness, compassion and in a caring manner and we commit to the following:

• Client information is held in strict and absolute confidence. Releases and permissions are obtained appropriately. Client information is only disclosed as required by law and when necessary to protect the client or others against imminent harm.
• We do not offer, recommend, or refer for abortions, abortifacients, or contraceptives. We are committed to offering accurate information about related risks and procedures.
• We strive to maintain the privacy and security of your Personally Identifiable Health Information (PIHI)
• We follow all applicable laws in the event of a breach that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice. 
• 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 anytime. Let us know in writing if you change your mind. 
• You may request a copy of your paper or electronic medical record and any other PIHI we have on you.  Ask us how to do this.  We will provide a copy or a summary of your health information, usually within 30 days of your request.  We may charge a reasonable, cost based fee for doing so.
• You may request us to make corrections in  your paper or electronic medical record, if you think it is incorrect or incomplete.  Ask us how to do this.  We may not be able to comply with your request, but we will reply to your request within 60 days. 
• You may request us to contact you in a specific way (for example by home or office phone) or to send mail to a different address.
• You may ask us to limit the information we use or share for treatment or operations, but we are not required to comply with your request. 
• You may request a list of those with whom we have shared your information.
• You may receive a copy of this privacy notice at any time, even if you have previously agreed to receive the notice electronically. 
• You may submit a complaint to us if you believe we have violated our privacy policy, by contacting our privacy officer and it will be investigated in a timely manner.  We will not retaliate against you for filing a complaint.

Our Use of Your PIHI and Disclosures

We commit to not use your Personally Identifiable Health Information (PIHI) except as permitted below or as required by this agreement or by law.  We may use and share your Personally Identifiable Health Information (PIHI) as follows:

• To provide you with services and treatment. We can use your health information and share it with other professionals treating you. Example: Sharing your ultrasound images with a medical professional for treatment purposes.
• To maintain your confidential client record.

• To operate our organization. We can use and share your health information to run our organization, improve your care, and contact you when necessary. Example: We use and share health information about you to manage your treatment and services. 

Comply with the law: We will share information about you if required by law 

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, talk to us. Tell us what you want us to do, and we will endeavor to follow your reasonable instructions.

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

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation.

If you cannot 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 the following cases, we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again, and we will honor that. We will not use personally identifiable information in fundraising materials without your consent.

Changes to the Terms of this Notice

We can change the terms of this notice, which will apply to all information we have about you. The new notice will be available upon request in our office and on our website.