HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed by Forge Health, LLC (“the Practice”) and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities.

• Get an electronic or paper copy of your record
  You can ask to see or get an electronic or paper copy of your health information. We will provide a copy or a summary, usually within 30 days of your request. A reasonable, cost-based fee may apply.

• Ask us to correct your record
  You can ask us to correct health information you think is incorrect or incomplete. We may say “no,” but we’ll tell you why in writing within 60 days.

• Request confidential communications
  You can ask us to contact you in a specific way (for example, cell phone vs. home phone) or to send mail to a different address. We will agree to all reasonable requests.

• Ask us to limit what we use or share
  You can ask us not to use or share certain health information for treatment, payment, or operations. While we may not be required to agree, if you pay in full out-of-pocket for a service, we will not share that information with your insurer unless required by law.

• Get a list of disclosures
  You can ask for a list of times we’ve shared your health information in the past six years, who we shared it with, and why. One list per year is free; a reasonable fee may apply for additional requests.

• Get a copy of this notice
  You can ask for a paper copy of this notice at any time.

• Choose someone to act for you
  If you have given someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights.

• File a complaint if you feel your rights are violated
  You can complain directly to us by contacting:
  [Your Business Name, LLC]
  Email: [email protected]
  Phone: 228-547-6032

Or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775

We will not retaliate for filing a complaint.

Your Choices

For certain information, you have the right to tell us your choices.

• You may direct us to share information with family, friends, or others involved in your care.

• You may direct us not to share your information in emergencies or disaster relief situations.

We will not share your information for:

• Marketing purposes

• Sale of your information

• Most uses of psychotherapy notes without your written permission.

Our Uses and Disclosures

We typically use or share your information in the following ways:

• Treat you
  We can share information with other professionals involved in your care.

• Run our organization
  We use information to manage our services and improve your care.

• Bill for your services
  We do not bill insurance. If you request reimbursement from a health savings account (HSA/FSA), we may provide documentation at your request.

Other legally required uses include:

• Public health and safety reporting

• Compliance with law

• Organ/tissue donation requests

• Work with medical examiners, coroners, or funeral directors

• Workers’ compensation, law enforcement, and government requests

• Responding to lawsuits or legal actions

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information (PHI).

• We will notify you promptly if a breach occurs that may compromise your privacy.

• We will follow the practices described in this notice.

• We will not use or share your information other than as described here without your written permission.

Changes to This Notice

We may change the terms of this notice at any time. The updated notice will apply to all information we maintain and will be available upon request, in our office, and on our website.