NOTICE OF PRIVACY PRACTICES – effective date 06/21/2011

You have the right to see and receive a copy of your health information with a few
exceptions:
- A written request must be submitted regarding the information you want to see.
- If you also want a copy of your records, we reserve the right to charge a reasonable fee for the copies

You have the right to request an amendment or change to your health information. You must submit a written request to make any changes. If you wish to include a statement in your file, please provide it in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but we will add the new information.

You have the right to receive a copy of this notice.
If we change any of the details of this notice, we will notify you of the changes in writing.

You may file a complaint with the Department of Health & Human Services, 200 Independence Ave. SW, Room 509F, Washington, D.C. 20201. You will not receive retaliation for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health and privacy, please contact our Clinic Office @ 408-782-1028.