The Alpine Center

(DBA: Alpine Integrated Health and Injury Clinics)

Notice of Privacy Practices

We Are Committed To Protecting Your Medical Information.
Under Federal Law, we are required to:
• Protect the privacy of your protected health information.
• Provide you with this Notice of Privacy Practices.
• Follow the practices and procedures set forth in the Notice.

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. If you have any questions about this Notice, please contact our Privacy Officer, David Hammond.

This Notice of Privacy Practices describes how we may use and disclose your protected
health information to carry out treatment, payment or health care operations and for other
purposes that are permitted or required by law. It also describes your rights to access and
control your protected health information. “Protected health information” is information
about you, including both your medical records and personal information such as your
name, social security number, address, and phone number. We may change the terms of
our notice at any time. Upon your request, we will provide you with the revised Notice of
Privacy Practices.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
In accordance with this Notice, and without asking for your express consent or
authorization, this clinic may use and disclose your protected health information for
treatment, payment or healthcare operations. For example:

Treatment: Your protected health information may be used and disclosed by us (doctor
and office staff) and others outside our office that are involved in your care and treatment
for the purpose of providing health care services to you. This includes another physician
who may be treating you or a physician to whom you have been referred (eg., a specialist
or laboratory).
Payment: Your protected health information will be used, as needed, to obtain payment
for your health care services from a third party, either directly or through a billing
service. This may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we recommend for you,
such as making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you for medical necessity, and undertaking utilization
review activities.

Notice of Privacy Practices Updated 9/1/2013

Healthcare Operations: We may use or disclose your protected health information, as
needed, in order to support the operations of this clinic. These activities include, but are

not limited to quality assessment activities, employee review activities, and conducting
or arranging for other activities.

For example, we may use a sign-in sheet at the registration desk where you will be asked
to sign your name and indicate your physician. We may also call you by name in the
waiting room when your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to remind you of your
appointment by a postcard mailed to the address provided by you and/or telephoning your
home and leaving a message on your answering machine or with the individual
answering the phone. We may send you birthday greetings by e-mail.

We may use or disclose your protected health information, as necessary, to provide you
with information about treatment alternatives or other health-related benefits and services
that may be of interest to you. We may use your de-identified medical information
(information that cannot be used to identify you) to assess where we can make
improvements in the care and services we offer.

We will share your protected health information with third party “business associates”
that perform various activities for the practice (e.g., billing, transcription services).
Whenever an arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written contract that
contains terms that will protect the privacy of your protected health information.

Others Involved in Your Healthcare: We may disclose to a member of your family, a
relative, a close friend or any other person you identify, your protected health information
that directly relates to that person’s involvement in your health care. If you are unable to
agree or object to such a disclosure, we may disclose such information, as necessary, if
we determine that it is in your best interest based on our professional judgment.

OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES
We may use and disclose your protected health information without asking for your
express consent or authorization in the following instances:

Emergencies: We may use or disclose your protected health information in an
emergency treatment situation. In this event, your physician shall try to obtain your
consent as soon as reasonably practicable after the delivery of treatment.

Communication Barriers: We may use and disclose your protected health information
if your physician or another physician in the practice attempts to obtain consent from
you, but is unable to do so due to substantial communication barriers, and the physician

Notice of Privacy Practices Updated 9/1/2013

determines, using professional judgment, that you intend to consent to use or disclosure
under the circumstances.
Required By Law: We may use or disclose your protected health information to the
extent that the use or disclosure is required by law. The use or disclosure will be made in
compliance with the law and will be limited to the relevant requirements of the law.

Public Health: We may disclose your protected health information for public health
activities and purposes to a public health authority that is permitted by law to collect or
receive the information. The disclosure will be made for the purpose of controlling
disease, injury or disability.
Communicable Diseases: We may disclose your protected health information, if
authorized by law, to a person who may have been exposed to a communicable disease or
may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight
agency for activities authorized by law, such as audits, investigations and inspections.

Abuse or Neglect: We may disclose your protected health information to a public health
authority that is authorized by law to receive reports of child abuse or neglect. In
addition, we may disclose your protected health information if we believe that you have
been a victim of abuse, neglect or domestic violence to the governmental entity or agency
authorized to receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to
a person or company required by the Food and Drug Administration to report adverse
events, product defects or problems, biologic product deviations, track products, enable
product recalls, make repairs or replacements, or conduct post marketing surveillance, as
required.
Legal Proceedings: We may disclose protected health information in the course of any
judicial or administrative proceeding, in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly authorized), and, in certain conditions,
in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose protected health information for law enforcement
purposes, so long as applicable legal requirements are met.
Coroners, Funeral Directors and Organ Donation: We may disclose protected health
information to a coroner or medical examiner for identification purposes, determining
cause of death or for the coroner or medical examiner to perform other duties authorized

Notice of Privacy Practices Updated 9/1/2013

by law. We may also disclose protected health information to a funeral director, as
authorized by law, in order to permit the funeral director to carry out its duties. We may
disclose protected health information to your designated personal representative upon
your death.
Research: We may disclose your protected health information to researchers when their
research has been approved by an institutional review board that has established protocols
to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose
your protected health information if we believe that the use or disclosure is necessary to
prevent or lessen a serious and imminent threat to the health or safety of a person or the
public. We may also disclose protected health information if it is necessary for law
enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we
may use or disclose protected health information of individuals who are Armed Forces
personnel. We may also disclose your protected health information to authorized federal
officials for conducting national security and intelligence activities, including the
provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us in
order to comply with workers’ compensation laws and other similar legally established
programs.
De-identified Information. We may use and disclose health information that may be
related to your care, but does not identify you and cannot be used to identify you.
Personal Representative. We may use and disclose protected health information to a
person who, under applicable law, has the authority to represent you in making decisions
related to your health care.
Required Uses and Disclosures: Under the law, we must make disclosures to you and,
when requested, to the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements of Section 164.500.
Authorization
Uses and/or disclosures, other than those described above, will be made only with your
written authorization, unless otherwise permitted or required by law elsewhere:

YOUR RIGHTS

Following is a statement of your rights with respect to your protected health information
and a brief description of how you may exercise these rights.
Notice of Privacy Practices Updated 9/1/2013

You have the right to revoke any authorization you have given to us, at any time.
To do so, you must submit a request in writing to our Privacy Officer.
You have the right to inspect and copy your protected health information. You may
inspect and obtain a copy of protected health information about you that is contained in
our files for as long as we maintain the protected health information. Under federal law,
however, you may not inspect or copy certain records. However, in some circumstances,
you may have a right to have a decision to deny access reviewed. Please contact our
Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information.
Your written request must state the specific restriction requested and to whom you want
the restriction to apply. We are not required to agree to a restriction you may request, but
if we do, we will abide by our agreement (except in an emergency).
You have the right to request to receive confidential communications from us by
alternative means or at an alternative location. We will accommodate reasonable
requests. We will not request an explanation from you for the basis of the request.
Please make this request in writing to our Privacy Officer.
You may have the right to have your physician amend your protected health
information. In certain cases, we may deny your request for an amendment. If we deny
your request for amendment, you have the right to file a statement of disagreement with
us, and we may prepare a rebuttal to your statement and will provide you with a copy of
any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if
any, of your protected health information. This right applies to disclosures for
purposes other than treatment, payment or healthcare operations as described in this
Notice of Privacy Practices. A patient’s request must state a time period not to exceed six
years. The right to receive this information is subject to certain exceptions, restrictions
and limitations. We will fulfill one request per 12-month period free of charge.
You have the right to request that your physician transmit your protected health
information to a designated party. Upon your signed written request we will send your
protected health information to a designated third party.
Out-of-Pocket-Payments. If you paid out-of-pocket in full for a specific item or service
and you have requested that we not bill your health plan, you have the right to ask that
your protected health information with respect to that item or service not be disclosed to a
health plan for purposes of payment or health care operations, and we will honor that
request.

Notice of Privacy Practices Updated 9/1/2013

Immunizations. We will disclose immunization data to schools if a patient’s legal
representative agrees to the disclosure.
Right to get notice of a breach. You have the right to receive written notification if the
practice discovers a breach of your unsecured protected health information and
determines through a risk assessment that notification is required.
The following uses and disclosures of your protected health information will be
made only with your written authorization:
1. Uses and disclosures of protected health information for marketing purposes and
fundraising communications; and
2. Disclosures that constitute a sale of your protected health information.
Right to an Electronic Copy of Electronic Medical Records. If your protected health
information is maintained in an electronic format, you have the right to request that an
electronic copy of your record be given to you or transmitted to another individual or
entity. We will make every effort to provide access to your protected health information
in the form or format you request, if it is readily producible in such form or format. If the
protected health information is not readily producible in the form or format you request,
your record will be provided in either our standard electronic format or a readable hard
copy form. We may charge you a reasonable, cost-based fee associated with transmitting
the electronic medical record.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe
your privacy rights have been violated by us. You may file a complaint with us by
notifying our Privacy Officer in writing. We will not retaliate against you for filing a
complaint. You may contact our Privacy Officer, for further information about the
complaint process.

Notice of Privacy Practices Updated 9/1/2013