OUR LEGAL RESPONSIBILITIES
We are required by law to give you this notice. It provides you on how we may use and disclose
protected health information about you and describes your rights and our obligations regarding the
use and disclosure of that information. We shall maintain the privacy of protected health
information and provide you with notice of our legal duties and privacy practices with respect to
your protected health information.
We have the right to change these policies at any time. If we change our privacy policies, we will
notify you of these changes immediately. This current policy is in effect unless stated otherwise.
If the policy is changed, it will apply to all your current and past health information.
You may request a copy of our notice any time. You may contact (Completely Centered Health, LLC at
(1116 Mandarin Drive Upper Marlboro MD 20774. PH: (202) 578-9001) at any time to request a copy of
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for your
treatment, payments, healthcare operations etc. but please be advised that not every use or
disclosure in a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you treatment. This
includes disclosing your protected health information to other medical providers, trainees,
therapists, medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate your
care. Also, the office staff may need to use and disclose your protected health information to
other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to obtain payment from an insurance
company or another third part. This may include providing an insurance company your protected
health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to
operate this medical practice. These activities include training students, reviewing cases with
employees, utilizing your information to improve the quality of care, and contacting you be
telephone, email, or text to remind you of your appointments.
If we have to share your protected health information to third party “business associates” such as
a billing service, if so, we will have a written contract that contains terms that will protect the
privacy of your protected health information.
We may also use and disclose your protected health information for marketing activities. For
example, we might send you a thank you card in the mail with a coupon for specialized services or
products. We may also send you information about products or services that might be of interest to
you. You can contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those
identified in this policy without your specific, written Authorization. You may give us written
authorization to use your protected health information or to disclose it to anyone for any purpose.
You can revoke this authorization at any time but will not affect the protected health information
that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your
initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about you to your
family members or friends if we obtain your verbal agreement to do so, or if we give you an
opportunity to object to such a disclosure and you do not raise an objection. For example, we may
assume that if your spouse or friend is present during your evaluation, that we can disclose
protected professional information to this person. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your best
interest based on our professional judgment if there is an urgent or emergent need.
Research; We will not use or disclose your health information for research purposes unless you give
us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to
organizations that handle organ procurement or organ, eye or tissue transplantation if it is
necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to
prevent or control disease, report adverse events from medications or products, prevent injury,
disability or death. This information may be disclosed to healthcare systems, government agencies,
or public health authorities. We may have to disclose your protected health information to the Food
and Drug Administration to report adverse events, defects, problems, enable recalls etc. if
required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight
agencies for audits, investigations, inspections or licensing purposes. These disclosures might be
necessary for state and federal agencies to monitor healthcare systems and compliance with civil
Required by Law: We will disclose protected health information about you when required to do so by
federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or
Lawsuits: We may disclose your protected health information in response to a court action,
administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in
response to a court order, subpoena, warrant, subject to all applicable legal requirements.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Access to medical records: You have the right to access and receive copies of your protected health
information that we use to make decisions about your care. You must submit a written request to
obtain your protected health information to the individual listed at the end of this privacy
policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the
protected health information and provide it to you.
Amendment: If you believe the protected health information, we have about you is incorrect or
incomplete, you may ask us to amend the information You will need to submit a written request on
why you feel the health information should be amended. We may deny your request to amend if you did
not send a written request or give a reason on why it should be amended. If we deny your request,
we will provide you a written explanation. We may deny your request if we believe the protected
health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed
your personal health information unless the disclosure was used for treatment, payment, healthcare
operations, was pursuant to a valid authorization and as otherwise provided in applicable federal
and state laws and regulations. You must submit a written request to obtain this “accounting of
disclosures” to the individual listed at the bottom of this policy. After your request has been
approved, we will provide you the dates of the disclosure, the name of the individual or entity we
disclosed the information to, a description of the information that was disclosed, the reason why
it was disclosed, and any additional pertinent information. This information may not be longer than
(STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the
right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected
health information we use or disclose about you for treatment, payment, or healthcare operations.
We shall accommodate your request except where the disclosure is required by law. We require this
be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you about
healthcare matters in a certain way and at a certain location. We must accommodate your request if
it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and
signed it via electronic means. To obtain this copy, contact the individual at the end of this
Complaints: If you believe your privacy rights have been violated, you may file a complaint with
our office. You also file a complaint with the U.S. Department of Health and Human Services. We
will provide you with the address to file your complaint with the U.S. Department
of Health and Human Services upon request.