Last Updated April 19, 2023
Easter Seals, Inc. (d/b/a "Easterseals") ("we," "our," or "us") understands that data privacy and the protection of personal information is important to you. This Privacy Notice explains how we collect, use and share your personal information, and your rights and choices regarding the personal information we collect about you.
Please read this Notice carefully to understand our policies and practices regarding your personal information and how we will process it. You can also click on the links below to navigate to a specific section.
- Scope of Notice
- Personal Information Collection
- How We Use Personal Information
- How We Disclose Personal Information
- Easterseals Affiliate Members
- Links to Other Sites
- Security of Personal Information
- Transmission of Health-Related Information
- Retention of Personal Information
- Your Rights and Choices Regarding your Personal Information
- International Transfers of Personal Information
- Information from Children
- Changes to this Notice
- Contact Us
1. Scope of Notice
This Privacy Notice applies to all donors, members, website visitors, business partners, employees, job applicants, and individuals who otherwise interact with Easterseals whom we collect personal information from. We often refer to your interactions with us as using our "services" throughout this Notice.
2. Personal Information Collection
We collect a variety of information as part of our operations, including personal information and other information. "Personal information" is any information that identifies, relates to, describes, is reasonably capable of being associated with, or could reasonably be linked, directly or indirectly, with an identifiable individual.
a. How We Collect Personal Information
Easterseals collects information, including personal information, from and about its donors, event attendees and program participants, individuals who interact with our affiliate members, employees and job applicants, individuals who visit our website and other individuals who choose to interact with us. We collect information from or about you in the following ways:
- Directly from you. We collect information directly from you when you make a donation, create a user profile on our website, attend an event or program we are offering, apply for employment or gain employment with us, when you visit our website, and when you otherwise voluntarily submit or provide information to us.
- Automatically. When you visit and interact with our website, we collect information automatically through cookies. For more information about cookies on our website, please visit the section below titled "Cookies."
- From our Affiliate Members. We rely on our affiliate members to provide us with information about the individuals they provide services to and interact with so that we can understand the impact of our and our affiliate members' programs and services, yield actionable insights, and drive future-forward decision making to ensure that our services and programs make the most impact in the communities we serve.
- From Other Sources. We may collect information about you from other sources and we may combine information from other sources with information we collect through our services or interactions with you. Examples of the other sources we most frequently collect information from includes national donor data bases and registries, and companies that compile mailing lists about individuals.
b. Types of Personal Information We Collect
The types of personal information we collect depends on how you interact with us, including whether the interaction is through one of our affiliate members or directly with us. In many cases, the personal information we collect will be apparent from the context in which you provide the information.
We collect the following types of personal information from you depending on how you interact with us (i.e., donor, employee, etc.).
|Categories of Personal Information||Categories of individuals|
|Contact Information. This includes your name, mailing address, email address, social media handle, or other similar identifiers.||
|Identification Information. This includes your SSN, driver's license number, passport number, or similar legal identification information.||
|Profile Information. This includes information about your activity and interactions with us, including your donor tendencies and donation history, information you voluntarily provide to us or that we collect from other sources regarding your interests, preferences, and characteristics. We compile this information we collect about you to better understand you.||
|Health Information. This is information about your health, disability, or medical condition which may include "Protected Health Information" (PHI).||
|Financial Information. This includes information about your wealth and financial status, income, credit card, bank account, or payment information.||
|Location Information. This includes information about your location.||
|Professional or Employment-Related Information. Current or past job history or performance evaluations.||
|Internet or other similar network activity. Browsing history, search history, information on your interaction with a website, application, or advertisement.||
|Interaction Information. This includes information about your attendance at events we host or programs we sponsor, as well as information about correspondence with us and other ways you interact with us.||
|Sensitive Personal Information. We may collect certain sensitive personal information including race, gender, and age information. This information is collected in aggregate form.||
We may not collect all of the above categories of information from each category of individual who interacts with us. Please note that if you voluntarily provide us with additional information when you interact with us that does not fit one of these categories of information or individuals set forth above, we will collect the information and use it for the purposes you direct or that we disclose to you.
As noted above, in certain circumstances, we may also collect "Protected Health Information." "Protected Health Information" ("PHI") is individually identifiable health information. We sometimes collect PHI when we gather information about the effectiveness of our programs in order to understand whether a program that we or our affiliate members offered resulted in improved outcomes for the individuals or communities our programs are designed to serve.
3. How We Use Personal Information
We use personal information for our legitimate business purposes to further our mission and for other purposes disclosed to you at the time data is collected. More specifically, we use personal information in the following ways:
- Provide our services, programs, and events to the communities and individuals we serve.
- Send you confirmations about event or program registration, or donations.
- Process donations and gifts made to Easterseals or our affiliate members.
- Understand our donor base and potential donors.
- Measure the effectiveness of our services, programs, and events, including services, programs, and events offered by our affiliate members.
- Communicate with you about our services, programs, events, happenings, and news.
- Respond to your comments, inquiries, and customer service requests.
- Market our events, services, programs, and potential donor opportunities to you. You may opt-out of marketing communications at any time.
- Provide you with employment, or consider you for employment with Easterseals.
- Process payroll and other benefits afforded to our employees.
- Improve and personalize our content and services.
- Monitor and analyze trends regarding our services, programs, and events, including services, programs, and events offered by our affiliate members.
- Protect against and prevent fraud, unauthorized transactions, and manage risk exposure.
- Enforce our legal rights and agreements.
- Comply with applicable legal requirements.
- Carry out any other purpose you consent to, that we disclose to you at the time your data is collected, or that you direct us to.
We may aggregate and de-identify personal information we collect from you to understand the effectiveness of our programs, services, and offerings, as well as to understand our donor base and donor trends. When we aggregate or de-identify information, it is no longer personally identifiable.
4. How We Disclose Personal Information
Easterseals may share your personal information in the following circumstances, and as otherwise described in this Notice:
- Affiliate Members. We share information with our affiliate members in order to understand and improve the impact of our and our affiliate members' programs, services, and offerings. Please see the section below titled "Easterseals Affiliate Members" for more information.
- Service Providers, Vendors, and Consultants. We rely on third parties to perform functions on our behalf. Some of these service providers include marketing service providers, payment service providers who help us process donations and pay our employees, cloud storage providers, website hosting platforms, client relationship management providers, HR or employee benefits providers, and content providers. We endeavor to ensure written agreements are in place with all service providers, vendors, and consultants where feasible and appropriate. All service providers, vendors, and consultants are required to use the information we disclose to them at our direction and only for the purpose(s) for which it was disclosed to them, and they are required to adhere to security and confidentiality measures.
- List Rental and Exchange Program. We may share certain information about our donors with national donor registration and list service providers in order to grow our donor base and more effectively reach current and prospective donors. If you do not wish for your information to be shared with these third parties, you may opt-out by contacting us via a method set forth in the "Contact Us" section below or by visiting our website and contacting us through a means listed on our website. If you would like to know which third parties participate in the list rental and exchange program, you may also contact us via one of the methods listed below.
- Law Enforcement Agencies, Courts, Regulators, Government Authorities, or Other Third Parties. We may disclose your information: 1) to apply with a legal obligation or court order; 2) when we believe in good faith that the law requires it; 3) at the request of governmental authorities conducting an investigation; 4) to verify or enforce our policies, procedures, terms of service, and other agreements, or to protect the rights, property, safety, and security of Easterseals, our members, vendors, business partners, service providers, affiliate members, website visitors, or the public; 5) to respond to an emergency; or 6) when we believe it is necessary or appropriate to prevent physical harm or financial loss, or in connection with an investigation of suspected or actual illegal activity.
- Successor Entities, Buyers, Transfers and Mergers and Acquisitions. We may disclose your information to a buyer, potential buyer, successor in interest, or to an organization in connection with a bankruptcy, transfer, merger or acquisition, or other transfer of some or all of Easterseals' or an affiliate's assets, which may include your information. If this occurs, we will endeavor to ensure that the successor entity uses your personal information in accordance with this Privacy Notice, or provides you with notice and a choice about future use of your personal information.
5. Easterseals Affiliate Members
Easterseals has a number of affiliate members throughout the United States who interact directly with the populations we serve by bringing Easterseals' mission and work directly into the community in which the affiliate member operates. While our affiliate member organizations are associated with and use Easterseals branding, they may have their own practices regarding how they collect, use, share, and retain information when you interact with them.
As described above, affiliate members share information with us, and we share information with our affiliate members. This information sharing occurs so that we can understand the impact of our and our affiliate members' programs and services, yield actionable insights, and drive future-forward decision making so that we can continue to further the Easterseals' mission of equity, inclusion, and access for individuals with disabilities.
Easterseals' website may contain links to other sites, including to our affiliate members, as well as links to non-affiliated third parties, such as social networks or business partners. These linked sites may have personal information collection, use, and disclosure practices that differ from Easterseals' practices. We encourage you to review the privacy policies of websites that you visit before sharing your personal information with them. Please also be aware that if you disclose personal information, PHI, or other sensitive information through public forums, at an event, or on online message boards, this information may be used by others. We take no responsibility for the content, security, or confidentiality of any information posted on or conveyed in these public spaces.
7. Security of Personal Information
Easterseals knows that information security is of the utmost important to our donors, affiliate members, website visitors, and individuals whose information we collect. We maintain reasonable technical, administrative, physical, and organizational safeguards in proportion to the sensitivity of information we collect that are designed to prevent unauthorized access, use, and disclosure of personal information.
However, no electronic data transmission or processing of personal information is completely secure, so we cannot guarantee the security of personal information. We encourage you to assist us with securing your personal information by using a strong password and not disclosing your login credentials, where applicable, to anyone. If we become aware of an incident that affects your personal information, we will investigate and comply with all reporting obligations.
8. Transmission of Health-Related Information
Easterseals understands the sensitivity of collecting and using health-related data. It is not Easterseals' intent to collect personally identifiable health-related information or PHI. If we do collect personally identifiable health-related information or PHI, it will not be used by or shared with entities other than Easterseals or our affiliate members, unless the information is de-identified. Any transfer of personally identifiable health-related data between Easterseals organizations will take place in a secure environment with access allowed only to certain qualified employees of Easterseals. Easterseals will comply with all regulations set forward by the Health Insurance Portability and Accountability Act (HIPAA). To learn more about HIPAA, visit the U.S. Department of Health and Human Services Office for Civil Rights.
9. Retention of Personal Information
We will retain your information only for as long as necessary to achieve the purpose for which it was collected. This may mean that we will continue to retain certain information even after we stop providing our services directly or indirectly to you, after you delete your user profile, or cease interacting with us, as required by law or for our legitimate business purposes. We may also retain de-identified, aggregated, or anonymous information that does not identify a particular individual. In all cases where we retain data, we do so in accordance with limitation periods and record retention obligations that are imposed by applicable law.
10. Your Rights and Choices Regarding your Personal Information
Easterseals offers various rights that are consistent with state consumer privacy laws. Easterseals offers the option to access, correct, and delete your personal information. If you are a registered user of our website, you can access your Easterseals profile and update your contact information and user preferences by clicking here. Upon your request, we will delete, aggregate, or de-identify personal information related to you that is retained in our organizational databases, unless we are required to continue to retain the information in an identifiable format. To exercise your right to deletion, or to modify or correct your information other than through the link above, please contact us via a method set forth in the below "Contact Us" section.
You can also change your communication preferences and opt-in or opt-out of marketing communications from Easterseals. To opt-out of receiving email communications, postal mail or from participating in the list rental and exchange program, or to request a disclosure of list rental and exchange information, please follow the directions below.
- Email: If you are a registered user of easterseals.com, login to change your email preferences.You may also opt out of certain non-essential marketing email communications using the "unsubscribe" link at the bottom of the email.
- Postal Mail: Opt-out of postal mail solicitations
- List Rental and Exchange: Opt-out of list rental and exchange program
- Disclosure Request: Request disclosure of list rental and exchange practices
We will endeavor to fulfill all requests within a reasonable timeframe.
- Functionality. These cookies are necessary for us to ensure that the website functions properly.
- Security. These cookies are necessary for us to mitigate the risk of data breaches and similar attacks by ensuring that requests are submitted to our website from proper domains.
- Authentication. These cookies allow us to authenticate user requests and to maintain session information related to users.
- Preference. These cookies allow our website to remember which events you have signed up or registered for, the products you place in your shopping cart, and to recognize your device.
- Advertising. These cookies allow us to provide you with more relevant advertisements.
- Analytics. These cookies enable us to learn more about how users and visitors interact with our website, including pages visited, how much time is spent on each pages, and similar information. We use this information in aggregate.
- Third-Party. These cookies are placed by third parties such as Google and social media networks. These cookies track and monitor how you interact with our services and other websites, provide us insight into how you interact with our website (such as analytics), facilitate account registration and login, and also enable the sharing of content from our services to these third parties. We do not control the data use or sharing practices of these third parties. If you do not wish to accept third party cookies, we encourage you to update your browser settings accordingly.
- Chrome: https://support.google.com/chrome/answer/95647?hl=en
- Firefox: https://support.mozilla.org/en-US/kb/cookies-information-websites-store-on-your-computer
- Edge: https://support.microsoft.com/en-us/microsoft-edge/delete-cookies-in-microsoft-edge-63947406-40ac-c3b8-57b9-2a946a29ae09
- Internet Explorer: https://support.microsoft.com/en-us/windows/delete-and-manage-cookies-168dab11-0753-043d-7c16-ede5947fc64d
- Safari: https://support.apple.com/guide/safari/manage-cookies-sfri11471/mac
12. International Transfers of Personal Information
Easterseals and all of its affiliate members are located in the United States, and all programming offered by Easterseals and its affiliate members occurs in the United States. Because of the global nature of the internet, the Easterseals website may be accessible from jurisdictions other than the United States, even though Easterseals does not operate, provide, or market its services outside of the United States. If you access the Easterseals website outside of the United States, your information will be transferred to and processed in the United States. Since the data protection laws of various countries differ, information transferred to the United States may not be subject to the same level of protection as the jurisdiction in which you reside. If you choose to access our website from a jurisdiction outside the United States, we rely on your consent to transfer the data to the United States. To the extent you do not consent to data transfers to the United States, please do not provide us with your personal information or visit our website.
13. Information from Children
Our website is not directed towards children under the age of 13. We do not knowingly collect personal information from anyone under the age of 13 through our website without parental consent. If you become aware that we have collected personal information from an individual under the age of 13 through our website without parental consent, please let us know so that we can take appropriate action.
14. Changes to this Notice
We may update this Privacy Notice from time to time. If we make material updates to this Notice, we will endeavor to provide you notice by placing a prominent notice on this website and/or sending an email notification of the change. We will also update the "last updated" date at the top of this policy. Any changes will be effective immediately on posting unless otherwise indicated. Continued use of our services after updates to our Notice will be deemed consent to the changes.
15. Contact Us
If you have any questions about this Notice or our information practices, please contact us by emailing us through this link or directly at email@example.com, calling us toll-free at 800-221-6827, or writing to us at:
Easter Seals, Inc.
Attn: Privacy Manager
141 W. Jackson Blvd
Chicago, IL 60604
Health Insurance Portability and Accountability Act (HIPAA)
Notice of Privacy Practices
Easter Seals Eastern Pennsylvania
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU* MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
*The use of "you" or "your" throughout this notice and all of this agency's HIPAA documentation can also be understood to mean your child when your child is the consumer and you are the legal guardian. Please review it carefully.
If you have any questions about this notice, please contact:
Deborah Hill, CFO
Easter Seals Eastern PA
1501 Lehigh Street, Suite 201
Allentown, PA 18103
610.289.4282 ▪ firstname.lastname@example.org
Our Pledge Regarding Health Information
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your therapist or others working in this agency. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information.
We are required by law to:
- make sure that health information that identifies you is kept private;
- give you this notice of our legal duties and privacy practices with respect to health information about you; and
- follow the terms of the notice that is currently in effect.
How We May Use and Disclose Information About You
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what is meant and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to therapists, doctors, nurses, technicians, health students or other personnel who are involved in taking care of you. They may work at our agency or at a doctor's office, lab, pharmacy or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes.
For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our consumers receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many consumers to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific consumers are.
Fundraising Activities: We may use health information about you to contact you in an effort to raise money for our not-for-profit operations. We may disclose health information to a foundation related to our practice so that the foundation may contact you in raising money for our practice. We only will release contact information such as your name, address and phone number and the dates you received treatment or services from us. Please let us know if you do not want us to contact you for such fundraising efforts.
As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify person or organization required to receive information on FDA-regulated products;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a consumer has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release health information if asked to do so by a law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process;
- about a death we believe may be the result of criminal conduct;
- about criminal conduct at our facility; and
- in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
Coroners, Health Examiners and Funeral Directors. We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about consumers to funeral directors as necessary to carry out their duties.
Your Rights Regarding Health Information About You
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another professional chosen by our agency will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, Pa 18103, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a reason that supports your request for an amendment.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- is not part of the health information kept by or for our agency;
- is not part of the information which you would be permitted to inspect and copy; or
- is accurate and complete.
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.
Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described. To request this list of disclosures, you must submit your request in writing to Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified therapist or teacher from use of your information.
We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to Deborah Hill,CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103, email@example.com. If we know that the electronic message has failed to be delivered, a paper copy of the notice will be provided. Even if you have received a notice electronically, you still retain the right to receive a paper copy upon request.
Changes To This Notice
We reserve the right to change this notice. 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. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you are readmitted to our services for treatment, we will offer you a copy of the current notice in effect.
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 Deborah Hill, CFO, Easter Seals Eastern PA, 1501 Lehigh Street, Suite 201, Allentown, PA 18103. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Health Information
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Acknowledgement of Receipt of This Notice
We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name, date. This acknowledgement will be filed with your records.