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If you want more information about our privacy practices or have questions or concerns, please contact us at the information provided below.

Additionally, if you are concerned that we may have violated your privacy rights, if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information, or to have us communicate with you by alternative means or at alternative locations, you may contact us at the following address:

Mark Stephany, M.D.

[Phone Number]

[Office Address]



Access. You may look at or request copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you may request an electronic copy. We will use the form and format you request if readily producible by us in that format. We may charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.

If you are denied a request for access, you may have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you may receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction. You may request additional restrictions on our use or disclosure of your health information by submitting a written request. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid for the services in full.

Alternative Communication. You may request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.

Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Notification of a Breach. We will provide you with notice of any data breach involving your health information as required by law.  

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically.


We will obtain your written authorization before using or disclosing your health information for purposes other than those provided for in this Notice (or as otherwise required by law), including for marketing purposes, the sale of your health information, or in relation to the sharing of most psychotherapy notes. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your health information, except to the extent that we have already taken action in reliance on the authorization or as required by law. 

Uses and Disclosures of Health Information With Your Authorization

We may use and disclose your health information without your authorization for different purposes, including treatment, payment, and health care operations. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records, may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

  • Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist or other caregiver providing treatment to you.

  • Payment. We may use and disclose your information to process payments for the services that we provide to you.  For example, if we accept a check for payment, we will deposit it. 

  • Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Uses and Disclosures of Heath Information For Treatment, Payment, and Healthcare Operations

Other Uses and Disclosures of Heath Information Without Your Authorization

We may use and disclose your health information without your authorization for additional purposes, including:

  • Serious Threat to Health or Safety. We may disclose your health information to any person without authorization if we reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual.

  • Public Health Activities. We also may disclose your health information for public health activities, including disclosures to:

o Prevent or control disease, injury or disability;

o Report child abuse or neglect;

o Report reactions to medications or problems with products or devices;

o Notify a person of a recall, repair, or replacement of products or devices;

o Notify a person who may have been exposed to a disease or condition; or

o Notify the appropriate government authority if we believe a patient has been the victim of a reportable event such as abuse, neglect, or domestic violence.

  • Individuals Involved in Your Care or Payment for Your Care.[1] We may disclose information about you to a patient representative, if you have one. If a person has the authority by law to make health care decisions for you, such as a parent or guardian, we will treat that patient representative the same way we would treat you with respect to your health information.

  • Disaster Relief.* We may use or disclose your health information to assist in disaster relief efforts.

  • National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody the health information of an inmate or patient.

  • Worker’s Compensation. We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

  • Law Enforcement. We may disclose your health information for law enforcement purposes as permitted or required by law, or in response to a subpoena or court order.

  • Health Oversight Activities. We may disclose your health information to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

  • Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

  • Required by Law. We may use or disclose your health information when we are required to do so by law, regardless of whether the purpose has been disclosed in this notice.

[1] Such unauthorized use or disclosure is allowed if you are not present, or the opportunity to agree or object to the use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance.

We are required by law to maintain the privacy of health information, to provide individuals with notice of our legal duties and privacy practices with respect to health information, and to notify affected individuals following a breach of unsecured health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect June 4, 2021, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.



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