This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

Get an electronic or paper copy of your record: You can ask to see, obtain, or have sent to someone else, a copy of your record.  If you are requesting a personal copy of your records, we may ask to review your records with you.  We will provide a copy or a summary of your health information, usually within two weeks of your written request.  We may charge a reasonable, cost-based fee. Please remember that electronic media is not always safe from unauthorized access and your confidentiality cannot be guaranteed in these circumstances.

Ask us to correct your record: You can ask us to correct health information about you that you think is incorrect or incomplete.  Ask us how to do this.

Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will agree to all reasonable requests. 

Ask us to limit what we use or share: We do not sell your personal information, nor do we use it for marketing.  Except for the disclosures listed below, we do not share your information, including psychotherapy notes, without a signed release of information that allows us to do so. You are allowed to retract that request at any time to stop any future disclosure of your information.  Further, you can ask us to limit, or not use, certain health information for treatment, payment, or business operations (data collection, auditing, etc.).  We are not required to agree to this request if it would affect your care. If you pay for a service or health care item out-of-pocket in full, we will not disclose that information to your health insurer, unless we are required to do so by law.

Get a copy of this privacy notice: You have the right to receive copies of this notice electronically (which can be obtained from our website) and/or in paper format.

Choose someone to act for you: 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 make sure the person has this authority and can act for you before we take any action, within the limits of the law.

File a complaint if you feel your rights are violated:  You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting or by contacting the Virginia Department of Health Professions at  or (800) 533-1560.  We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.  If you have a clear preference for how we share your information, please tell us.  In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care (with a valid release, in a clinically appropriate format).  If you are not able to tell us your preference, for example if you are significantly impaired, we may share your information if we believe it is in your best interest or your desire. Retroactive consent may be obtained in emergency situations.

Our Uses and Disclosures: We typically use or share your health information in the following ways.

Treat you: We can use your health information and share it with other professionals within LooseLeaf, Inc.  We will not release information to another health care provider without your consent, except as noted below.  Example: A doctor treating you for an injury contacts us about your treatment, we will first require a written release of information from you.

Operation of our practice: We can use and share your health information to operate our practice, improve your care, and contact you when necessary.  Example: We use health information about you to manage your treatment and services

Bill for your services: We can use and share your health information to bill and get payment from payment entities, if applicable.  

How else can we use or share your health information? 

We are allowed or required to share your information in other ways, without a written consent, usually in ways that contribute to the public good, such as public health.  We have to meet many conditions in the law before we can share your information for these purposes.  

Help with public health and safety issues: We can share health information about you for certain situations such as:  Reporting suspected child or elder abuse or neglect; Preventing or reducing a serious threat to anyone’s health or safety, including your own, and/or Emergency psychiatric or medical situations.

Comply with the law, lawsuits, worker’s compensation, legal or administrative actions: We will share information about you if state/federal law or administrative agencies require it, including 1) with the Department of Health and Human Services; 2) with law enforcement if compelled by the law, a court or administrative order, or a subpoena; 3) with health oversight agencies for activities authorized by law; 4) for special government functions such as military, national security, and presidential protective services, 5) with our professional liability carrier and attorney as necessary,  and 5) with worker’s compensation if required by law.

Work with a medical examiner or funeral director: We can share health information with a coroner or medical examiner if required by law.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you.  Any new notice(s) will be available upon request, in our office, and on our web site.