Effective Date: October 15, 2025
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.
Ithaka Wellness Center is committed to protecting the privacy of your protected health information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment, or healthcare operations, and for other purposes that are permitted or required by law. It also describes your rights regarding your health information.
We are required by law to:
We may use and disclose your PHI for the following purposes:
We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services. For example:
We may use and disclose your PHI to obtain payment for services we provide. For example:
We may use and disclose your PHI for our healthcare operations, including:
We may use and disclose your PHI to:
We may use or disclose your PHI without your authorization in the following situations:
We will disclose your PHI when required to do so by federal, state, or local law.
We may disclose your PHI for public health activities, such as:
We may disclose PHI to health oversight agencies for activities such as audits, investigations, inspections, or licensing actions.
We may disclose PHI in response to a court order, subpoena, discovery request, or other lawful process.
We may disclose PHI to law enforcement officials for purposes such as:
We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of others.
We may disclose PHI for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
We may release PHI to coroners, medical examiners, or funeral directors as necessary to carry out their duties.
Other uses and disclosures of your PHI not covered by this Notice will be made only with your written authorization. You may revoke your authorization at any time in writing, except to the extent that we have already taken action in reliance on your authorization.
We will obtain your specific authorization for:
You have the following rights with respect to your PHI:
You have the right to inspect and obtain a copy of your medical records and other health information. To request access, you must submit a written request. We may charge a reasonable fee for copying and mailing your records.
If you believe that information in your medical record is incorrect or incomplete, you may request an amendment. Your request must be in writing and include a reason for the amendment. We may deny your request in certain circumstances.
You have the right to request an accounting of certain disclosures of your PHI made by us during the six years prior to your request. Your request must be in writing.
You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request, except in certain situations where you pay out-of-pocket in full for services and request that we not share information with your health plan.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing and must specify how or where you wish to be contacted.
You have the right to obtain a paper copy of this Notice upon request, even if you have agreed to receive it electronically.
You have the right to be notified if we discover a breach of your unsecured PHI.
We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. The current Notice will be posted in our office and on our website, and will include the effective date.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address below. All complaints must be in writing.
You will not be penalized or retaliated against for filing a complaint.
For more information about this Notice or to exercise your rights, please contact:
Privacy Officer
Ithaka Wellness Center
Email: paul@ithakawellness.com
To file a complaint with the Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
By becoming a patient of Ithaka Wellness Center, you acknowledge that you have been provided with an opportunity to review this Notice of Privacy Practices. Your signature on our acknowledgment form indicates that you have been informed of our privacy practices.
This Notice of Privacy Practices is effective as of October 15, 2025, and complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.