Notice of Privacy Practices

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI)

PAYMENT: We use and disclose your PHI to your insurance company in order to receive payment for your covered health expenses VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: We may disclose PHI to government agencies about suspected abuse, neglect, or domestic violence.

OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION

Other uses or disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law.  You may revoke an authorization at any time in writing effective with the date of the letter of revocation.

HEALTHCARE: We may use and disclose PHI to other healthcare providers (physicians, healthcare professionals, laboratories, or hospitals) to better assist in your diagnosis and treatment.

MEDICAL RECORDS REQUEST: We will disclose your PHI if we receive a request from another physician who is treating you or will be treating you with a signed request from you.  We will disclose your PHI to an insurance company if we have filed a claim on your behalf.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have certain rights regarding protected health information that our office maintains about you.

RIGHT TO ACCESS YOUR PROTECTED HEALTH INFORMATION: you have the right to review or obtain copies of your PHI records.  Your request to review and/or obtain a copy of your PHI records must be made in writing.  We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance.

FOR INFORMATION REGARDING EXERCISING YOUR RIGHTS: You may exercise any of the rights described above by contacting our Office Manager.  See the end of this Notice for the contact information.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services.  All complaints must be made in writing and sent to the Office Manager listed at the end of this Notice.  We support your right to protect the privacy of your PHI.  We will not retaliate against you or penalize you for filing a complaint.

CONTACT Anasazi FOUNDATION if you have any questions or complaints about this Notice or you want to submit a written request to our office in any of the previous sections of the Notice, please call (480) 892-7403 or write to us at:

Anasazi Foundation

Att: Office Manager

1424 South Stapley Drive 

Mesa, AZ 85204

You may obtain a full copy of Anasazi Foundation’s privacy notice at the office.