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Privacy Practices 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

Get an electronic or paper copy of your medical record

•You can ask to see or get an electronic or paper copy of your medical record and other health information we have about 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.

Ask us to correct your medical record

Request confidential communications

Ask us to limit what we use or share

Get a list of those

with whom we’ve shared information

Get a copy of this privacy notice

Choose someone to act for you

•You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

•We may say “no” to your request, but we’ll tell you why in writing within 60 days.

•You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

•We will say “yes” to all reasonable requests.

•You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

•If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

•You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, 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). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

•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.

•If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

•We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated•You can complain if you feel we have violated your rights by contacting us using the information on page 1.

•You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,

Washington, D.C. 20201, calling 1-877-696-6775, or visiting


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

Your Choices

. 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 follow your instructions.

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

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

In the case of fundraising:

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

•Share information in a disaster relief situation

•Include your information in a hospital directory

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.

•Marketing purposes

•Sale of your information

•Most sharing of psychotherapy notes

•We may contact you for fundraising efforts, but you can tell us not to contact you again.


We typically use or share your health information in the following ways.

Treat you• We can use your health information and Example: A doctor treating you for an share it with other professionals who are injury asks another doctor about your treating you. overall health condition.

Run our • We can use and share your health Example: We use health information organizationinformation to run our practice, improve about you to manage your treatment and your care, and contact you when

Bill for your • We can use and share your health Example: We give information about you servicesinformation to bill and get payment from to your health insurance plan so it will pay health plans or other entities. for your services.

Our Uses and Disclosures

continued on next page

How else can we use or share your health information? 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 have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Help with public health • We can share health information about you for certain situations such as: and safety issues• 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

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

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

•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.

•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.

•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.


Federal confidentiality protections annotated in 42CFR part 2, guarantees the strict confidentiality of information about all persons receiving substance abuse prevention and treatment services. They are designed to protect patient privacy and thereby attract individuals into treatment who might not otherwise attend.

The federal confidentiality law protects any information about a patient if the patient has applied for, or received any alcohol or drug abuse related services, including assessments, diagnosis, detoxification, counseling, and group counseling, treatment and referral for treatment with another agency.

Confidential information may be shared without the patient’s consent under the following conditions:

" Internal communications

" Medical emergency

" Qualified Service Organizations with signed agreement

" Duty to Report/child abuse or neglect

" Duty to Warn

" Crime committed on program premises

" Subpoenas and court orders

" Patient is a danger to themselves or others

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 of it.

•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:

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, in our office, and on our website.


This Notice of Privacy Practices applies to Road to Me Recovery Services and Arvada West Family Medicine.

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