7111 E 21st St N Ste 104
Kansas Care Connect, LLC Wichita, KS 67206

(316) 370-2406
kansascareconnect.com
info@kscareconnect.com

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

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 say “yes” to all reasonable requests.

Your Rights (continued)

Ask us to limit what we use or share

• You can 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 to share that information with your health insurer.
• We will say “yes” unless a law requires us to share that information.

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

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask.
• We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures.
• We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.
• 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, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information above.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
  200 Independence Avenue, S.W., Washington, D.C. 20201
  Phone: 1-877-696-6775
  Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
• 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 in the situations described below, talk to us and tell us what you want us to do.

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
• Contact you for fundraising efforts

If you are not able to tell us your preference (for example, if you are unconscious), we may share your information if we believe it is in your best interest.

We may also share your information to lessen a serious and imminent threat to health or safety.

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

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

In the case of fundraising:

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

Our Uses and Disclosures

How do we typically use or share your health information?

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 who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run 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 health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways — usually for public benefit, such as public health and research.

Help with public health and safety issues

We can share health information about you for situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services.

Organ and tissue donation

We can share your health information with organ procurement organizations.

Medical examiner or funeral director

We can share information with a coroner, medical examiner, or funeral director when an individual dies.

Workers’ compensation, law enforcement, and government requests

We can use or share health information:

• For workers’ compensation claims
• For law enforcement purposes
• With health oversight agencies
• For government functions such as military or national security

Lawsuits and legal actions

We can share health information in response to a court order, administrative order, or subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will notify you promptly if a breach occurs.
• We must follow the practices described in this notice.
• We will not use or share your information other than as described unless you give written permission.
• You may change your mind at any time in writing.

Changes to This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you.

The updated notice will be available:

• Upon request
• In our office
• On our website

Effective Date: 08/01/2023

Applies To

Kansas Care Connect, LLC

Contact:
Rachael Rivero
rrivero@kscareconnect.com
(316) 370-2406