Privacy Officer Contact Information: 734.390.9009 [email protected] Effective Date of Notice: 2/15/2024


This notice describes how medical information about you may be used and disclosed and howyoucangetaccess to this information. Please review it carefully.

Your Rights

You have the right to:

• Receive an electronic or paper copy of your medical record
• Correct your medical record or health information
• Request confidential communications
• Ask us to limit information we use or share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures

We typically use and share your information in the following ways:

  • Treat you; use and share your health information with other professionals treating you
  • Run our organization; to improve your care and contact you when necessary.
  • Advertising and promotion; we may use your story and ultrasound images with all identifyinginformation removed or de-identified to protect your privacy
  •  Help with public health and safety issues such as:
  •  Preventing disease, helping with product recalls or reporting adverse reactionstomedications
  • Reporting suspected abuse, neglect, domestic violence, or reducing a seriousthreattoanyone’s health or safety

Sienna Women’s Health

  • Do health research
  • Comply with state or federal laws requiring sharing of information, including withtheDepartment of Health and Human Services to ensure we’re complying privacy laws.
  • Respond to organ and tissue donation requests to organ procurement organizations
  • Work with a medical examiner or funeral director; or coroner when an individual dies
  • Address workers’ compensation claims, for purposes of or for law enforcement officials, andother government requests like:
  • health oversight agencies for activities authorized by law
  • or special government functions such as military, national security, and presidential
    protective services
  • Respond to lawsuits and legal actions; in response to a subpoena, court or administrativeorder

Your Rights

When it comes to your health information, you have certain rights, explained here:
Receive an electronic or paper copy of your medical record and other health informationwehaveabout you

  • Ask us how to see or get an electronic or paper copy of your medical record
  • We will usually provide this within 30 days of your request and may charge areasonable,cost-based fee.

Correct your medical record or health information about you that you think is incorrectorincomplete

  • Ask us how to do this. We may say “no” to your request, but we’ll tell you why inwritingwithin60 days.

Request confidential communications

  • Ask us to contact you in specific ways (for example, home or office phone) or tosendmail toadifferent address. We will say “yes” to all reasonable requests.

Ask us to limit information we use or share

  • Ask us not to use or share certain health information for treatment, payment, or our operations.We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not tosharethatinformation for the purpose of payment or our operations with your health provider. Wewill say“yes” unless a law requires us to share that

Get a list of those with whom we’ve shared your information

  • Ask for a list (accounting) of the times we’ve shared your health information for six yearspriortothe date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, andhealthcareoperations, and certain other disclosures (such as any you asked us to make).

Sienna Women’s Health

  • We’ll provide one accounting a year for free but will charge a reasonable, cost-basedfeeif youask for another one within 12 months.

Get a copy of this privacy notice

  • Request a paper copy of this notice at any time, even if you have agreed to receivethenoticeelectronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, thatperson 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 takeanyaction.

File a complaint if you believe your privacy rights have been violated

  • You can complain if you feel we have violated your rights by contacting us.
  • You can file a complaint with the U.S. Department of Health and Human Services OfficeforCivilRights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling1-877-696-6775, or visiting
  • 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 youhaveaclear preference for how we share your information in the situations described below, talktous. Tell uswhat you want us to do, and we will follow your instructions.

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
  • Share information in a disaster relief situation
  • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we mayshareyourinformation if we believe it is in your best interest. We may also share your informationwhenneededto lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact youagain.

Our Responsibilities:

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

For more information:

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information wehaveaboutyou. The new notice will be available upon request, in our office, and on our website.

Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practicesidentifies:

1. how medical information about you may be used or disclosed;

2. your right stoaccess your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information;

3. your rights to complain if you believe your privacy rights have been violated;

4. our responsibilities for maintaining the privacy of your medical information.

The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy Practices and is the patient, or the patient’s personal representative.