Notice of Privacy Practices &
Your PHI Patient Rights


This Notice of Privacy Practices describes established privacy guidelines followed by our staff in relation to your protected health information (PHI). This notice will explain most situations of how and when we may use and disclose your PHI. Please note that despite our best efforts, this notice may not include every possible situation. Please address any questions to the Compliance Officer as noted at the end of this notice.

This notice addresses information we maintain regarding your health, health status, and the healthcare services provided at our office. This information may include information collected and recorded in this office, as well as information received from other healthcare providers. The information may be in written, electronic, or spoken form. It may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity; and similar types of health-related information. We are required by law to give you this notice. It will explain how we may use and disclose PHI about you and explain your rights regarding the use of that information.


For Treatment - We may use or disclose information with healthcare providers who are involved in your care. Personnel in our office may share information to coordinate your care. Family members and other healthcare providers involved in your care outside of this office may require information about you.

For Payment - We may use or disclose PHI to bill for services provided and receive payment from an insurance company or other third party. Insurance companies may need information regarding a specific visit or procedure or require information to pre-approve future services.  

For Healthcare Operations - We may use or disclose PHI to operate and/or improve the office, its programs, and services.

Health Information Exchange (HIE) - HIE is a computer based, secure method of exchanging or disclosing patient health information with other organizations, for the purposes of healthcare treatment, payment, and operations.

Business Associates – We may contract with business associates who may perform certain functions and activities on our behalf. Our business associates are required to safeguard your PHI. 

Appointment Reminders - We may contact you directly or leave messages as a reminder of your appointment for services.

Insurance Verification - We may contact your insurance company via telephone or their website to verify your insurance enrollment status.  

Treatment Alternatives - We may contact you regarding possible treatment alternatives.

Health-Related Products and Services – We may contact you regarding health-related products or services that may be of interest.


As Required by Law - We will use and disclose PHI when required by federal, state, or local law or by a court order. We may disclose PHI in response to a subpoena, warrant, summons, or similar process subject to all applicable legal requirements.  

For Abuse Reports - We may use or disclose PHI to meet legally mandatory reporting requirements. The use is intended to prevent a serious threat to your health and safety or the health and safety of the public.

Research - We may use and disclose PHI for research projects if you have consented to participate in the study. If you have voluntarily consented to participation in a research study, researchers will be subject to the same PHI restrictions.  

De-Identified Information - We may use or disclose PHI in a way that does not identify who you are.

Organ and Tissue Donation - If you are an organ donor, we may use or disclose PHI to organizations that manage organ procurement to facilitate organ donation, transport, and transplantation. 

Military, Veterans, National Security, and Intelligence - If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may use or disclose PHI to military command or other government authorities as required.

Workers Compensation - We may use or disclose PHI for workers compensation or similar programs.  

Public Health Risks - We may use or disclose PHI for public health reasons to prevent or control disease, injury, or disability, or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health Oversight Activities - We may use or disclose PHI to a health oversight agency for audits, investigations, inspections, or licensing purposes. 

Lawsuits and Disputes – We may use or disclose PHI in response to a court administrative order due to your involvement in a lawsuit or dispute. We may release PHI in response to a subpoena subject to all applicable legal requirements.

Coroners, Medical Examiners, and Funeral Directors - We may use or disclose PHI to a coroner or medical examiner when requested.


Right to Inspect and Copy - With certain exceptions, you have the right to make a written request to receive a copy of your health records.

Right to Amend - You have the right to request that an amendment to your record be made if you think the information is incorrect or there is information missing. Your request must be in writing and must include a reason for the request. Pine Springs Health may deny your request for an amendment if the amended information was not originally created by Pine Springs Health, is not part of PHI that we maintain, was not permitted to be inspected and/or copied, or is already accurate and complete. A copy of your amendment request will be put in your record even if we do not agree to amend the record itself. 

Right to Request Confidential Communications - You have the right to request that we communicate with you about your PHI in a way that complies with your Communication Preferences.

Right to a List of Disclosures - You have the right to an “accounting of disclosures” of your PHI. This is a list of disclosures of PHI about you for purposes other than treatment, payment, healthcare operations, and a limited number of special circumstances involving national security, correctional institutions, and law enforcement. The list will exclude any disclosures we have made based on your written authorization.

Right to Request Restrictions - You have the right to request a restriction or limitation on the use of your PHI. The request must be in writing and describe what information you wish to be restricted and to whom. If the request is approved, the restrictions may be terminated in writing at any time in the future.

Right to Request Restrictions to Health Plan - You have the right to request a restriction of disclosure to your health plan for treatments you pay cash for. The request must be in writing and describe what information you wish to be restricted and the name of your health plan. This restriction does not extend to follow-up care or disclosures authorized to another provider unless the restriction request specifies. Pine Springs Health does have the right to bill your health plan if we are unable to obtain payment from you. 

Right to Receive Notification of a Breach - If there is a breach involving your PHI, we will contact you in writing with a description of the breach, the type of information involved, the steps you should take to protect yourself, a summary of what is being done, and the person you can contact for further information.  

Right to File a Complaint - You have the right to file a complaint if you feel your privacy rights have been violated. You will not be penalized for filing a complaint. You may contact the Clinic Manager, or the Office for Civil Rights at:

Medical Privacy, Complaint Division  

U.S. Department of Health and Human Services  

200 Independence Avenue, SW  

HHH Building, Room 509H  

Washington, D.C. 20201  

Toll free phone: 877-696-6775  

866-627-7748 (phone)

Right to a Paper Copy of this Notice - You have a right to a paper copy of this notice at any time.