Privacy Policy

Notice of Privacy Practices

We are required by law to maintain the privacy of protected health information to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.  We must follow the privacy practices that are described in this Notice while it is in effect.   This Notice is in effect February 1, 2013 and will remain in effect until we replace it.

We reserve the right to change our Notice of Privacy Practices and the terms of the Notice at any time, provided such changes are permitted by the law.  We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may print this Notice out for yourself or request a copy of the Notice at any time, when visiting our office.

Uses and disclosures of health information

We use and disclose health information about you for treatment, payment, and healthcare operations.    Some information such as HIV-related information, genetic information, alcohol and/or substance abuse record and mental health records may be entitle to special confidentially protection under New Hampshire 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 to a physician or other health care provider providing treatment to you.  For example: we may provide your health information to a specialist providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for the treatment or services we provide to you or that another entity involved with your care. Payment activities included billing, collections, claims, and determination of eligibility and coverage to obtain payment from you, an insurance company, or another third party.  For example: we may send claims to your dental insurance company containing certain health information.

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, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provided performance, conducting training programs, accreditation, licensing, or credentialing activities.

Persons Involved in Care or the payment of your care:  We may disclose your health information to your family, friends, or any other individual identified by you when they are involved in your care or in the payment for your care.  Additionally, we may disclose information about you to a patient representative.  In an emergency circumstances or in the event of you are incapacity, we will disclose your health information to  base on a determination using  our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your care.  If a person has the authority by law to make health care decisions for you, we will treat that person the same way we would treat you with respect to your health information.

Disaster Relief and required by law: We may use or disclose your health information to assist in disaster relief efforts or required by law to do so.

Public Health Activities:  We may use or disclose your health information for public health activities including:

  • Prevent or control disease, injury or disability
  • Reporting child abuse or neglect
  • Reporting reactions to medications or problems with products or devices;
  • Notify a person of a recall, repair or replacement of products or devise;
  • Notify a person who may have been exposed to a disease or condition or
  • Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

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

We will disclose your health information to the following departments or activity when required to investigate or determine compliance with HIPAA:

  • Secretary of HHS
  • Worker’s Compensation
  • Law Enforcement
  • Health oversight activity
  • Judicial and Administrative proceedings
  • Research
  • Coroners, Medical Examiners, and Funeral directors

Your Health Information Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practicable do so. (You must make a request in writing to obtain access to your health information.  You may obtain a form to request access by using the contact information listed at the end of Notice.  We will charge you a reasonable cost-based fee for expenses such as copies and staff time.  You may also request access by sending us a letter to the address at the end of this Notice.  If you request copies, we will charge you $0.25cents for each page and $15.00 per hour for staff time to locate and copy your health information and postage if you want the copies mailed to you.  If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.  If you prefer, we will prepare a summary or an explanation of your health information for a fee.  Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

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

Right to Request Restrictions:  You have the right to request additional restrictions on the use of disclosure of your PHI by submitting a written request to the Privacy Official.  Your written requisition must include (1) what information you want of 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 purposed of carrying out payment or health care operation, 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 our practice in full.

Alternative Communication:   You have the right to request that we communicate with you about your health information by alternative means or to alternative locations.  You must request this in writing.  Your request must specify the alternative means or location, and provide satisfactory explanation how payment s will be handled under the alternative means or location you requested.  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, we will provide you with a written explanation of why we denied it and explain you rights.

Right to Notification of a breach:  You will receive notification of a breach of your unsecured protected health information as required by law.

Electronic Notice:  You may receive a paper copy of the Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by e-mail.


If you want more information about our privacy practices or have any questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or 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 complain to us using the contact information listed at the end of this Notice.  You also may submit a written complaint to the U.S. Department of Health and Human Services.  We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:  Shirley Kharazi

Telephone:  603-882-5455      Fax: (603) 886-7999


Address: 182 Central Street, Hudson, NH 03051

Website Design & Hosting by Whitemountain Webarts