Sunrise Health Care, PC
Effective Date: June 1, 2014


If you have any questions about this notice, please contact the Practice administrator by dialing 719-577-9977.
Each time you visit a physician, or other healthcare provider in this clinic, a record of your visit is made. Typically, symptoms, physical examination, test results, diagnosis, treatment, plan for future treatment, and insurance information is included. This notice applies to all of your records generated by this practice, whether made by practice personnel, agents of the practice, or your doctor.
Our Responsibilities: We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
Uses and Disclosures:
How we may use and disclose medical information about you.
The following categories describe examples of the way we use and disclose medical information:
For Treatment: We may use medical information about you to provide your treatment or services. We may disclose medical information about you to nurses, technicians, medical students, other physicians, and/or hospital personnel who are involved in your care.

For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party player. We may also tell your health plan about treatment you are to receive to determine whether your plan will cover it.

For Health Care Operations: Members of the staff may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. We may remove information that identifies you from this set of medical information to protect your privacy.
We may also use and disclose medical information to/for:

  • Remind you that you have an appointment;
  • Assess your satisfaction with our services;
  • Inform you about possible treatment alternatives;
  • Inform you about health-related benefits or services;
  • Inform Funeral Directors consistent with applicable law:
  • Population based research activities relating to improving health or reducing health care costs; and
  • Conducting training programs or reviewing competence of health care professionals.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include services for radiology, laboratory testing, and transcription services. We may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Research: In the event we have a research project, we may disclose information to researchers only after an institutional review board has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Future Communications: We may communicate to you via newsletters, mail outs, or other means regarding treatment options, health related information, disease-management programs, or other community based initiatives or activities in which our practice participates.

Organized Health Care Arrangement: This practice is presenting you this document as a notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information to assist in reviewing past treatment as it affects your current treatment.
Affiliated Covered Entity: Caregivers at other facilities or practices may have access to protected health information at their locations to assist in reviewing past treatment information as it affects your present treatment.

As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • Funeral Directors, Coroners and Medical Directors
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs.


Although your health record is the physical property of the facility that compiled it, you have the right to:

Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. The charge for inspection is $35.00 for the first 20 minutes (minimum amount) or $75.00 per hour. The charge for copying your medical information is $14.50 for the first 10 pages, $.50 for each additional page, and $.35 for over 40 pages. Both payments for inspect and copy are required in advance of services.

Amend: If you feel that medical 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 the information is kept by or for the clinic.
We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of the disclosures we make of your medical information.

Request Restrictions: You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so.

A Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. The first copy is free but there is a charge for each additional copy.
To exercise any of your rights, please obtain the required forms from our staff and submit your request in writing.


We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. In addition, each time you visit the clinic for treatment or health care services, we will have available a copy of the current notice in effect.


If you believe your privacy rights have been violated, you may file a complaint with the practice by contacting the main number and asking for the Administrator or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, contact the Administrator. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.


Other uses and disclosures of medical 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 medical 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 medical 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 your records of the care that we provided to you.

Privacy Official
Name: Administrator
Telephone:719-577-9977 and talk to our receptionist
Address: Sunrise Health Care, PC
4020 Palmer Park Blvd. 101B
Colorado Springs, CO 80909