Notice of Privacy Practices
We are required by law to maintain the privacy and security of your protected health information. Please make sure to review this notice. It describes how the information we have about you may be used and disclosed. You can ask for a paper copy of this notice at any time, by calling the number on the back of your ID card. We will provide you with a paper copy promptly.
Notice of Privacy Practices English
Notice of Privacy Practices – Spanish
Your Rights:
When it comes to your health information, you have certain rights. Please use the appropriate form below to notify us that you would like to invoke your rights:
Authorization for Disclosure and Revocation of Authorization
We will not use or share your information other than as described in the Notices of Privacy Practices unless you tell us we can in writing.
Authorization for Disclosure of PHI – English
Authorization for Disclosure of PHI – Spanish
An authorization can be discontinued at any time by alerting us in writing. Please use below:
Discontinuation of Authorization – English
Discontinuation of Authorization – Spanish
Get your medical record – Inspect and Copy
You can ask to see your medical record and other health information we have about you by completing the below form. We will provide a copy or a summary of your health information, usually within 60 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record/Request Amendment
You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request an amendment – English
Request an amendment – Spanish
Request Alternate Communications
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.
Request for Alternate Communications – English
Request for Alternate Communications – Spanish
Ask us to limit what we use or share- Request Restrictions
You can ask us not to use or share certain health information for treatment, payment, or our operations.
Request Restrictions – English
Request Restrictions – Spanish
You can also discontinue or terminate the restrictions by completing below:
Restriction Termination – English
Restriction Termination – Spanish
Get a list of those with whom we’ve shared information- Accounting of Disclosures
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.
Accounting of Disclosures- English
Accounting of Disclosures – Spanish
File a complaint if you feel your rights are violated – Privacy Complaint
You can file a complaint if you feel we have violated your rights by submitting below to Doctors HealthCare Plans or you can file a complaint directly with the U.S. Department of Health and Human Services Office for Civil Rights:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/ complaints/
We will not retaliate against you for filing a complaint.
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Last Updated: 01/11/2023
