Notice of Privacy Practices

Effective Date: [Month Day, Year]

This notice explains how Northeast Arkansas Pain Medicine Clinic and The Pain Center of Jonesboro may use and disclose your medical information, how you can access that information, and what rights you have under federal privacy law. Please read it carefully.

Your Rights

You have rights regarding your health information. In most cases, you may:

Get a copy of your medical record

You may ask to inspect or receive a paper or electronic copy of your medical record and other health information we maintain about you. We generally respond within the time required by law. We may charge a reasonable, cost-based fee when permitted.

Ask us to correct your record

If you believe information in your record is incorrect or incomplete, you may ask us to amend it. We may deny your request in some situations allowed by law, but if we do, we will explain that decision in writing.

Request confidential communications

You may ask us to contact you in a specific way, such as at a certain phone number, at a certain mailing address, or by another reasonable method. We will accommodate reasonable requests.

Ask us to limit certain uses or disclosures

You may ask us not to use or disclose certain health information for treatment, payment, or health care operations. We are not always required to agree, but we will consider your request.

If you pay for a service or item in full out of pocket, you may ask us not to share that information with your health insurer for payment or health care operations purposes, and we will comply unless the law requires otherwise.

Get a list of certain disclosures

You may request an accounting of certain disclosures of your health information made by us during the period allowed by law. This list will not include every disclosure, such as disclosures for treatment, payment, health care operations, or disclosures you authorized.

Get a copy of this notice

You may ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.

Choose someone to act for you

If you have given someone medical power of attorney, or if someone is your legal guardian or other valid personal representative, that person may exercise your rights and make choices about your health information to the extent allowed by law.

File a complaint

If you believe your privacy rights have been violated, you may file a complaint with us using the contact information listed below. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

Your Choices

In certain situations, you may tell us your preferences about how we share your information.

If you are able to tell us your preference, we will follow it. This may include sharing information with:

• family members, friends, or others involved in your care or payment for your care

• a person responsible for your care

• a disaster relief organization, when appropriate

If you are not able to tell us your preference, for example if you are unconscious or in an emergency, we may share information when we believe it is in your best interest or necessary to prevent a serious threat to health or safety.

We will not use or disclose your information for the following purposes without your written authorization, unless the law allows or requires otherwise:

• marketing, when authorization is required by law

• the sale of your health information

• most uses or disclosures of psychotherapy notes, if we maintain them

You may revoke a written authorization at any time by notifying us in writing, except to the extent we have already acted on it.

How We May Use and Disclose Your Information

We may use and disclose your health information for the following purposes:

Treatment

We may use your health information to provide, coordinate, or manage your care. For example, we may share information with physicians, nurses, therapists, pharmacies, imaging providers, laboratories, hospitals, or other health care professionals involved in your treatment.

Payment

We may use and disclose your information to bill and collect payment for the services we provide. For example, we may share information with your health plan to verify coverage, obtain authorization, process claims, or determine benefits.

Health Care Operations

We may use and disclose your information to operate and improve our practice. For example, we may use your information for quality review, staff training, licensing, accreditation, auditing, compliance, business planning, and administrative activities.

Appointment reminders and health-related communications

We may contact you with appointment reminders, follow-up information, care-related instructions, or information about treatment alternatives or health-related benefits and services that may be relevant to your care.

Individuals involved in your care

We may share relevant information with a family member, friend, caregiver, or other person involved in your care or payment for your care, unless you object or the law requires otherwise.

Public health and safety activities

We may disclose information when required or permitted for public health and safety purposes, including reporting disease, adverse events, abuse, neglect, domestic violence, product recalls, or threats to health or safety.

Health oversight activities

We may disclose information to government agencies for activities authorized by law, such as audits, inspections, investigations, licensure, and compliance reviews.

Legal and law enforcement purposes

We may disclose information in response to a court order, subpoena, lawful process, or certain law enforcement requests, as allowed or required by law.

Workers’ compensation

We may disclose information as authorized by workers’ compensation laws and similar programs.

Research

We may use or disclose health information for research when permitted by law and when required approvals or safeguards are in place.

Organ, tissue, and donation purposes

If permitted by law, we may disclose information to organizations involved in organ procurement, tissue donation, or transplantation.

Medical examiners, coroners, and funeral directors

We may disclose information to a medical examiner, coroner, or funeral director when authorized by law.

Business associates

Some services for our practice are carried out by third-party vendors that help us operate our business. These vendors are required by contract and law to protect your information.

Our Responsibilities

We are required by law to:

• protect the privacy of your protected health information

• provide you with this notice of our legal duties and privacy practices

• follow the terms of the notice currently in effect

• notify you if a breach occurs that may have compromised the privacy or security of your information, as required by law

We may change the terms of this notice at any time. Any revised notice will apply to all health information we maintain, including information we created or received before the change. The current version of this notice will be available in our office and on our website.

Questions or Complaints

If you have questions about this notice, want to exercise your rights, or wish to file a complaint with us, contact:

[Privacy Officer or Contact Title]Northeast Arkansas Pain Medicine Clinic / The Pain Center of Jonesboro505 E Matthews Ave. Ste. 103Jonesboro, AR 72401Phone: (870) 972-0411Fax: (870) 933-8011Email: Scheduling@jonesboropain.com

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.