To schedule an appointment or for any questions, you may reach our office at 812-372-6274

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

  • Get an electronic or paper copy of your medical record.
  • Ask us to correct your medical record
  • Request confidential communications
  • Ask us to limit what we use or share
  • Get a list of those with whom we’ve shared information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you feel your right are violated – You can file a complaint with the U.S. Dept. of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or by 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 you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what 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 may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

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

  • To Treat You – We can use our 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 you8r health insurance plan so it will pay for your services.
  • Help with public health and safety issues – We can share health information about your for certain situations such as:
    • Do Research – We can use or share you 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 if it wants to see if we’re complying with federal privacy law.
    • Respond to organ and tissue donation requests – We can share health information about you with organ procurement organizations.
    • Work with a medical examiner or funeral director – We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
    • Address worker’s compensation, law enforcement, and other government requests – We can use or share health information about your for workers compensation claims, law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, or for special government functions.
    • Respond to lawsuits and legal actions – We can share health information about you in response to a court or administrative order, or in response to a subpoena.

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see

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. You may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.


Effective date of this notice – 9/9/2014

Privacy Practice Official for this Facility – Lisa A. Hladik, RN.
She can be reached at (812) 372-6274 or at