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.

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

Get a paper copy of your medical record:
• We will provide a copy or a summary of your health information, usually within 30 days of your request.
• You can ask for a paper copy of your medical record & other health information we have about you.

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

Request confidential communications: We will say “yes” to all reasonable requests.
• You can ask us to contact you in a specific way (for example, home or office phone).

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

Get a list of those with whom we’ve shared information:
• We will include all the disclosures except for those about treatment, & health care operations, & 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 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, & why.

Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time. We will provide you
with a paper copy promptly.

Choose someone to act for you:
• If you have given someone medical power of attorney or if someone is your legal guardian, that person
can exercise your rights & make choices about your health information.
• We will make sure the person has this authority & 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 directly, or by filing a complaint with
the U.S. Department of Health & 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
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

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, & we will follow your instructions to the best of our ability.

In these 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
• Contact you for fundraising efforts.
• 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 & imminent threat to health or safety.

In these 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.

Our Uses and Disclosures.

How do we typically use or share your health information?
We typically use or share your health information in the following ways:

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

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

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 & research. We
are required to meet many conditions in the law before we can share your information for these
purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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

To comply with the law. 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.

To work with a medical examiner. We can share health information with a coroner, medical examiner, or
examiner or funeral director funeral director when an individual dies.

To address law enforcement & government organizations. We can use or share health information about you:
• 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, & presidential protective
services

To respond to lawsuits & legal actions. We can share health information about you in response to a court or
administrative order, or in response to a subpoena.

                                                                                                                        Responsibilities
• We are required by law to maintain the privacy & 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 & privacy practices described in this notice & 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: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice
We can change the terms of this notice, & 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 web site.

This Notice of Privacy Practices applies to the following organizations.
CityBridge Urgent Care 910 W Parker Rd, Ste. 102, Plano, Texas 75075  972-972-8930 citybridgeurgentcare.org