1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this Notice.

• You have the right to ask us to limit how your personal medical information is used and given out for your care, for billing, and for our business reasons. If you give us a written request to limit this information, we will consider your request. Please understand that under the law, we do not have to accept it. You may also ask us to limit your medical information that we use and give out to a family member, friend or other person who is involved in your care or the payment for your care.
• You have the right to see and get a copy of your medical or billing records or other written information that we may use to make decisions about your care, with some limited exceptions. In most cases, we may charge a reasonable fee for our costs in copying and mailing the information you have asked for. There are certain circumstances where we cannot agree to your request. In these cases, you will have the right to review the reasons why we did not agree with your request. A licensed health care professional named by FamilyCare, P.C. / Alliance Medical Group of Greater Waterbury / G.W.M.R.I. will perform the review.
• You have the right to request that we add to ("amend") your health record if you believe that the information is incorrect or if you believe that important information is missing. Your request must be made in writing and must state the reason for your request. If we disagree with your request, you may ask us to include your written statement requesting the change as part of your record. We will also provide you with a written statement that lists the reasons why we disagreed with your request.
• You have the right to get a listing or "accounting" of those people or organizations that received your medical information from us. This listing includes disclosures made by FamilyCare, P.C. / Alliance Medical Group of Greater Waterbury / G.W.M.R.I. or by others on our behalf. It does not include disclosure for treatment, payment and our business operations or certain other exceptions. To request an accounting of disclosure, you must send us a request in writing. The first list provided within a 12-month period will be free. After that, we may charge you our costs.
• You have the right to receive a paper copy of this Notice at any time upon request from any of our service or treatment areas. You may also get a copy of this Notice on our website. Reference Cover Summary Sheet for a current website address.
• You have the right to request, in writing that we communicate with you about your health matters in a different way or at a different place. For example, you can ask that we contact you only at a certain phone number or address that may be different from your home address. We will agree to reasonable requests.

1. To file a complaint with the government, you may contact:
     Office of Civil Rights
   U.S. Department of Health and Human Services
   200 Independence Avenue, S.W., Room 509 F
   Washington, D.C. 20201
2. To file a complaint with us, you should contact the Privacy Officer referenced on the Cover Summary Sheet.
3. You will not be retaliated against for filing a complaint.

• To you or someone who has the legal right to act for you (your personal representative),
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
• Where required by law, and
• In certain emergency circumstances.

• Individuals Involved in Your Care or Payment for Your Care - Unless you object, we may disclose health information about you to a family member, close personal friend or other person you identify, including clergy, who is involved in your care. These disclosures are limited to information necessary for that person to help with your care or in arranging payment for your care.
• Disaster Relief - We may disclose health information about you to an organization assisting in a disaster relief effort.
• Emergencies - We may use or disclose your health information as necessary in emergency treatment situations. We will attempt to obtain permission from you or your representative as soon as possible.
• Communication Barriers - We may use and disclose your protected health information if your doctor or another doctor in the practice tries to get permission from you but cannot because of language barriers. In this case, the doctor will use reasonable judgment that you intend to give permission to use or disclose information under the circumstances.
• As Required By Law - We may disclose your health information when required by law to do so.
• Public Health Activities - We may disclose your health information for public health activities. These activities may include, for example:
  1. reporting to a public health or other government authority for the purpose of preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting births and deaths;
  2. reporting to the Federal Food and Drug Administration (FDA) issues concerning problems with products and product recalls, etc., or
  3. to notify a person who may have been exposed to or is at risk of spreading a communicable disease, if authorized by law.
• Reporting Victims of Abuse or Neglect - If we believe that you have been a victim of abuse or neglect, we may use and disclose your health information to notify a government authority. This will happen if we are authorized or required by law or if you agree to the report. For child / elder abuse or neglect, we will disclose your health information to government authorities.
• Health Oversight Activities - We may disclose your health information to a health oversight agency for activities authorized by law. These may include, for example, Medicare audits, investigations, State Health Department inspections and licensure actions or other legal proceedings.
• Legal Proceedings - We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information.
• Law Enforcement - We may disclose your health information for certain law enforcement purposes. These include, for example, complying with reporting requirements, reporting emergencies, or suspicious deaths; to comply with a court order, warrant, or similar legal process; to identify or locate a suspect or missing person; or to answer certain requests for information concerning crimes.
• Research - Your health information may be used for research purposes, but only if the privacy aspects of the research have been reviewed and approved by our Institutional Review Board that has reviewed the research proposal and set standards to ensure the privacy of your protected health information.
• Coroners, Medical Examiners, Funeral Directors, and for Organ Donation: Deceased Individuals - The protections that are afforded under the Privacy Regulations do not end upon death. Rather, the rights that the individual had survive their death and are transferred to any person acting upon the deceased individual?s behalf. There are however, certain disclosures that are permitted without authorization; provided that the P.H.I. disclosed is not drug / alcohol, psychiatric or HIV related information. The disclosures are to:
  1. law enforcement officials if it is suspected that the death may have resulted from criminal conduct;
  2. Chief Medical Examiner for the purpose of identifying a deceased individual, determining cause of death, or other duties authorized by state law;
  3. funeral directors to carry out their duties and
  4. Organ Procurement Organizations (O.P.O.) and other entities for the purpose of facilitating donation and transplantation, if you are an organ donor.
• To Avoid a Serious Threat to Health or Safety - Should it be necessary to prevent a serious threat to your health or safety or the health or safety of others, we may use or disclose health information. This type of disclosure will be limited to someone able to help lessen or prevent the threatened harm.
• 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:
  1. for activities believed necessary by appropriate military command authorities,
  2. for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or
  3. to foreign military authority if you are a member of the foreign military services.
     
     We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
  
   
• Workers' Compensation - We may use or disclose your health information to comply with laws relating to workers? compensation or similar programs.
• Inmates / Law Enforcement Custody - If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the institution or official for certain purposes including the health and safety of you and others.
• Fundraising Activities - We may use your contact information such as your name, address and phone number and the dates you received treatment or services, to contact you in an effort to raise money for the Greater Waterbury Health Network. We also may disclose contact information for fundraising purposes to a foundation related to the Greater Waterbury Health Network.
• Appointment Reminders - We may use or disclose health information to remind you about appointments.
• Treatment Alternatives and Health Related Benefits and Services - We may use or disclose your health information to inform you about treatment alternatives and health related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about products or services that we believe may be beneficial to you.

Your authorization or permission is required for other uses of your medical information.

Except as described in this Notice, we will use and disclose your health information only with your written authorization. When you sign our consent for Treatment, Payment and Operations (T.P.O.), you allow us to use and disclose your health information for treatment, payment and health care operations. A written authorization must specify other particular uses or disclosures that you may allow. You may revoke an authorization to use or disclose health information, in writing, at any time. If you revoke an authorization, we will no longer use or disclose your health information for the purposes covered by that authorization, except where we have already relied on the authorization.