Skip to main content

Health Insurance Portability and Accountability Act (HIPAA)

Notice of Privacy Policy

Holton Health and Wellness Services is a primary health care practice serving the SAU community

This notice is effective October 15, 2019, and describes how information about you may be used or disclosed, and how you can get access to this information. Please review it carefully.

A federal regulation, known as the “HIPAA Privacy Rule,” requires that we provide detailed notice in writing of our privacy practices; we know that this Notice is long. The HIPAA Privacy Rule requires us to address many specific things in this notice.

Our Pledge Regarding Health Information

We understand that health information about you and your health care is personal.  We are committed to protecting health information about you.  We create a record of the care and services you receive from us.  This Notice describes your rights as our patient and our obligations regarding the use and disclosure of health information. Law requires us to:

  • Make sure that health information that identifies you is kept private;
  • Provide you with this Notice of our legal duties and privacy practices with respect to health information about you; and
  • Comply with the terms of the Notice that is currently in effect.

How We May Use and Disclose Protected Health Information About You

The following categories describe the different ways we may use and disclose health information for treatment, payment or health care operations.  The examples included with each category do not list every type of use or disclosure that may fall within that category.


We may use and disclose health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our office, at the hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, testing or treatment. For example, we may use and disclose health information when you need a prescription, lab work, x-ray, or health care services. In addition, we may use and disclose health information about you when referring you to another health care provider, including electronic transmission when necessary to other physicians for treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.


We may use and disclose health information about you so that the treatment and services you receive from us may be billed to, and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations:

We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so that others may use it to study health care delivery without learning who our specific patients are.

Appointment Reminders:

We may use and disclose health information to contact you as a reminder that you have an appointment. Please let us know if you wish us to use a different telephone number or address to contact you for this purpose.

Marketing, Health-Related Services and Treatment Alternatives:

In order to use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you, we will obtain written authorization from you prior to the use or disclosure for marketing purposes.


We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information or by specific written authorization from you.

As Required by Law:

We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety:

We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans:

If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation:

We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks:

We may disclose health information about you for public health activities as required or permitted by law. These activities generally include the following: To prevent or control disease, injury or disability; to report births and certain deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify person or organization required to receive information on FDA-regulated products; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes:

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court order, or appropriate administrative order as required by law, that is signed by a judge. For other requests, we comply with a valid patient authorization.

National Security, Protective Services for the President and other Intelligence Activities:

We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law, so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations.

Your Rights Regarding Health Information About You

Right to Inspect and Copy:

You have the right to inspect and receive a copy of health information that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information please contact the HHWS office manager. A written request is required. If you request a copy of health information about you, we may charge you a reasonable fee for copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and copy health information only in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend:

If you feel that health information we have about you is incorrect or incomplete, you may request that we amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing to HHW, and must be contained on one page of paper legibly handwritten or typed. In addition, you must provide a reason that supports your request for an amendment. We may deny your request in certain cases, including if it is not in writing or if you do not give us a reason for the request.

In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the health information kept by or for our practice;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

Right to Receive Confidential Communications:

You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you may request that we only contact you at work or by mail to a post office box. You must make your request in writing. You must specify how you would like us to contact you (for example, by regular mail to your post office box and not your home). We are required to accommodate reasonable requests.

Right to Request Sharing or Restrictions:

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will verify that the person has this authority and can act for you before we take any action. You have the right to request a restriction or limitation on the health information that we use for disclosure about you for treatment, payment and health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not disclose information to your spouse about a surgery you had. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively affect the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

You have the right to request a restriction of your protected health information to your health plan if you pay out of pocket for the healthcare item or service prior to services being rendered.

To request a restriction, you must make a request in writing to HHWS.

Right to Receive an Accounting of Disclosures:

You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to HHWS. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time-period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to a Paper Copy of this Notice:

You have a right to receive a paper copy of this Notice at any time. To obtain a copy of this notice, please speak with the receptionist at HHWS.

Changes to this Notice

We reserve the right to make changes to this Notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility.


If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact HHWS. You will not be penalized for filing a complaint.

Acknowledgement of Receipt of this Notice

We will request that you sign a separate form or notice acknowledging you have received a copy of this Notice.