Notice of Privacy Practices

West Valley Research Clinic

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

Personal identifiable information about your health, your health care, and your payment for health care is called Protected Health Information.  We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information.  Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure. 

We must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time.

If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at  You also may ask for a copy of the Notice by calling us at (623) 253-0065 and asking us to mail you a copy or by asking for a copy at your next appointment.

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent

We may use and disclose your Protected Health Information as follows without your permission:

For treatment purposes.  We may disclose your health information to doctors, nurses and others who provide your health care.  For example, your information may be shared with people performing lab work or x-rays.

For health care operations.  We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide.  We may disclose your information to students training with us.  We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.

When required by law.  We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies.  For example, we may have to report abuse, neglect or certain physical injuries.

For activities related to death.  We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial.  We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.

To avert a threat to health or safety.  In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat. 

Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object

In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object:

To your family, friends or others involved in your care.  We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition.  We may release your health information to organizations handling disaster relief efforts.

Uses and Disclosures of Your Protected Health Information That Require Your Consent

The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:

Clinical Research. If you decide to participate in a clinical research trial at WVR Clinic, you will be asked to provide your protected health information which may be disclosed to other healthcare entities involved in your care in order to gather more information about you for ongoing research purposes. Additionally, your PHI may be disclosed to the following governing entities overseeing Research conduct or healthcare professionals directly involved in your care:

Institutional Review Board-Governing agency designated to monitor biomedical research involving human subjects.

Food and Drug Administration (FDA)-Federal agency of the Department of Health and Human Services

(Under the HIPAA Privacy Rule, covered entities may use or disclose protected health information from existing databases or repositories for research purposes either with individual authorization as required at 45 CFR 164.508, or with a waiver of individual authorization as permitted at 45 CFR 164.512(i).)

Healthcare Providers-We will use/disclose protected health information to your healthcare providers as medically necessary and only with your written authorization. We may need to collect medical records in order to obtain current information about your health for research purposes only. 

Your Rights Regarding Your Protected Health Information

You have the following rights related to your Protected Health Information:

To inspect and request a copy of your Protected Health Information.  You may look at and obtain a copy of your Protected Health Information in most cases.  You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information which you cannot access by law.  If we use or maintain the requested information electronically, you may request that information in electronic format.

To request a restriction on the use or disclosure of your Protected Health Information.  You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request.  An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service.  If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations.  We cannot limit uses or disclosures that are required by law.

To request confidential communication methods.  You may ask that we contact you at a certain address or in a certain way.  We must agree to your request as long as it is reasonably easy for us to do so. 

To receive notice if your records have been breached.  WVR Clinic will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you. We will review any suspected breach to determine the appropriate response under the circumstances.

To obtain a paper copy of this Notice.  Upon your request, we will give you a paper copy of this Notice. 

If you have any questions about these rights, please contact us at (623) 253-0065.

Authorization to Release PHI:

This privacy notice was explained to me and I understand my rights regarding the use and disclosure of my protected health information.

I understand that I will be notified if any revision is made to this Privacy Notice.

I understand that by law, I have the right to revoke my authorization at any time and this Privacy Notice will remain in effect from the date of authorization for three years unless my authorization is revoked or revised.

Patient Name (Print)_____________________________________________

Patient Signature________________________________________________