Notice of Privacy Practices

Wellness@Work, PA Effective Date: 11/09/2025 Address: 837 S. Hillside, Wichita KS 67211 Privacy Officer: Nancy Knowles Phone: 316-684-4888 | Fax: 316-684-1570 Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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.

 1. 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 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. 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 insurer.
  • 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.
  • 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.
  • 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.
  • File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting Nancy Knowles at the address or phone number listed above. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

 

2. 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.

  • 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.
  • 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.

 

3. Our Uses and Disclosures

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: We request your radiology report from an imaging center to help with your adjustment plan.
  • 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 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.

  • 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, or preventing or reducing a serious threat to anyone’s health or safety.
  • 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.
  • 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, or 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.

 

4. 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.

 

Acknowledgement of Receipt I acknowledge that I have received a copy of Wellness@Work, PA’s Notice of Privacy Practices.

 

Patient Signature: _________________________________ Date:    ___/___/___