Privacy Practices

Learn about patient privacy at Lafayette Pain Care.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice applies to all patients at all locations. 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.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We will 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.
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, personal phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
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 daily practice management. 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 for the purpose of payment or reimbursement 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 identifying the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care clinic operations, and certain other disclosures (such as any you asked us to make). We’ll provide one account 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 have agreed to receive the notice 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 and can act for you 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.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, 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 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 or personal emergency situation

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 your health or safety.

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

Marketing purposes

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.
Manage 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 in ways that contribute to the public good, such as public health and research. We have to meet many legal conditions before we can share your information for these purposes. For more information see:

Help with public health and safety issues.

We can share health information about you for certain 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, safety, or well-being
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 we are complying with federal privacy law.

Address workers’ compensation, law enforcement, and other government requests.

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
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.

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 ensure you receive 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. If you tell us we can, you may change your mind at any time. Please let us know in writing if you change your mind.

Changes to the Terms of this Notice

We 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 website.


This notice is in effect, effective January 1, 2016, and is reviewed annually.

Patient Consent Form

To protect your personal health information, we use a HIPAA consent form. We understand you have certain rights to privacy regarding your protected health information. These rights are given to you under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We understand by signing a consent, you authorize us to use and disclose your protected health information to carry out:

Treatment (including direct or indirect treatment by the other healthcare providers involved in your treatment)
Obtaining payment from third-party payers (e. g. your insurance company)
The day-to-day healthcare operations of the physician’s practice

You may revoke your consent in writing at any time. However, any use or disclosure that occurred prior to the date the consent was revoked is not affected.

We ask all of our patients to complete a patient authorization form while being under your physician’s care. This form specifies those other persons whom you authorize to receive limited personal health information such as disclosure of any appointments and those who are released to pick up existing prescriptions.

We reserve the right to change the terms of the HIPAA consent form and patient authorization form. You may contact us any time to obtain the most current copy of the notices. We will, however, never change your authorization without your approval.

For questions about the credit monitoring service option, please contact our Call Center at 888-849-0976.