Privacy Statement

NOTICE OF PRIVACY PRACTICES

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

You have the right to: 

  • Get a copy of your paper or electronic medical record

  • Correct your paper or electronic medical record

  • Request confidential communication

  • Ask us to limit the information we share

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

  • Get a copy of this privacy notice

  • Choose someone to act for you

  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we: 

  • Tell family and friends about your condition

  • Provide disaster relief

  • Provide mental health care

  • Market our services and sell your information

  • Raise funds

Our Uses and Disclosures

We may use and share your information as we: 

  • Treat you

  • Run our organization

  • Bill for your services

  • Help with public health and safety issues

  • Do research

  • Comply with the law

  • Respond to organ and tissue donation requests

  • Work with a medical examiner or funeral director

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

  • Respond to lawsuits and legal actions

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.

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 for the purpose of payment or our operations with your health provider. 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, who we shared it with, and why.

  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). 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 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 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. 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 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.

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

  • Marketing purposes

  • Sale of your information

  • Most sharing of psychotherapy notes

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 use or share your health information in the following ways:

Treat you

We 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 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 conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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 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 if it wants to see that 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 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 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

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.

Pregnancy Resource Center 

1427 Sutter Pl Clovis, NM 88101

(575)-935-5433

Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices (NPP) is provided to all clients. This Notice of Privacy Practices identifies: 1) how medical information about you may be used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information. 

The undersigned certifies that he/she has read the foregoing, has been offered a copy of the Notice of Privacy Practices and is the client, or the client’s personal representative. 

 

Name of Client_________________________  

Signature of Client_________________________ Date Signed: _________________

Name of Client’s Personal Representative _________________________  

Signature of Representative_________________________  Date Signed: _________________

______________________________________________________________________________

For Internal Use Only

__________________________________________________________ 

Name of Employee Signature of Employee 

If applicable, reason client’s written acknowledgement could not be obtained:

__Client was unable to sign. 

__Client refused to sign 

__Other_________________________________________________________

Pregnancy Resource Center

REQUEST FOR SERVICES

LIMITATION OF SERVICES

This facility is a nonprofit medical clinic. The medical services are provided by licensed medical professionals, mostly volunteers. 

Our Advocates are lay people, not necessarily licensed or degreed personnel. The counseling obtained here is not intended as a substitute for professional counseling. 

All information is kept confidential, except if reporting laws apply or if we believe or hear that you are in danger of hurting yourself or others. 

Our Clinic does not benefit financially from your decision regarding your pregnancy. All our services are free. We do not perform or refer for abortion, but we do provide information on services so that you are equipped to make an informed choice about your pregnancy. 

For the privacy of our patients, our clinic and its agents, we do not consent to any recording on the premises. Any violation of this policy may result in prosecution.

The urine pregnancy test is 97% to 99% accurate; however, a physician must confirm the results of your test. Whether the test is positive or negative, you should follow-up with a licensed physician. 

Sexually Transmitted Infection testing and educational services are provided by medical professionals or trained individuals; follow-up with a licensed physician for further STI testing is recommended.

The center reserves the right to close due to inclement weather. It is the client’s responsibility to check center closings during these conditions and reschedule a new appointment time.

The center services and resources are intended for all persons who genuinely seek our caring help.  Any attempt to obtain these services or resources under false pretenses is also not permitted.

I understand the above and willingly enter into a relationship of accepting help and assistance from the pregnancy center.

By signing below, you acknowledge that you have been provided the opportunity to review our Notice of Privacy Practices.

Place Copy of Photo ID Here 


The undersigned does hereby attest to the accuracy of her name, address and date of birth as listed below and that this is a true and accurate photograph of herself, which will be placed in her record for privacy protection purposes.

______________________________________     _____________________________________

Name Date of Birth

______________________________________________________________________________

Address

______________________________________      _____________________________________

Signature Date