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Genesis World Mission, Inc.

dba Garden City Community Clinic

215 W 35th StreetGarden City ID 83714

208-384-5200

www.gardencityclinic.org

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.

Because we are a registered free clinic in Idaho (Statute 39-77) and neither bill nor communicate with health insurance

companies electronically, Genesis World Mission dba Garden City Community Clinic is considered a non-covered entity

under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, for purposes of good patient car

we have instituted privacy practices to secure your protected health information to the best of our ability.

What we will and wont do with your records

1. We will keep your protected information confidential while using it for the purposes of treatment and health care

operations. This means we will not disclose your health care records and other individually identifiable healthinformation to anybody without your consent, except in the case of an emergency, unless for these purposes. For

example, we may need to share information with other providers or specialists involved in the continuation of yourcare. There are also legally required or allowable reasons we may disclose your information such as internal

operational reviews, to business associates, certain public health activities, to avert a serious and imminent threat o

harm to yourself or others, and for research conditions.

2. You must give us written permission to disclose your information to anybody outside the scope listed above. At th

bottom of this form is a place for you to designate who you may or may NOT want us to disclose to.

3. We will not use your name, condition and/or photos of you for marketing and/or fundraising purposes unless we

have your written consent.

What you may request with regard to your records

1. You may request restrictions on certain uses and disclosures of protected health information.2. You may request to receive confidential communication of protected health information from us by alternative or a

alternative locations.

3. You may request access, inspect, and copy your protected health information . As per Idaho statute 39-77 which

relates to free clinics record keeping, we will retain your patient records for a minimum of five years following thelast date of provision of services.

4. You may request an amendment to your protected health information .

This notice is effective as of September 15 2013, and we are required to abide by the terms of the Notice of Privacy Practice

currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice

provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will

be posted on the effective date and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below in the event you feel your privacy rights

have been violated. We will not retaliate against you for filing a complaint.

For more information about our Privacy Practice, please contact:

Garden City Community Clinic

Clinic Manager

215 West 35th Street

Garden City, ID 83714208-384-5200 x211

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I have read the Notice of Private Practices (updated Sept 15 2013) of the Garden City Community Clinic.

I understand the circumstances in which my Protected Health Information may be used by this practice and its agents.

I agree to the conditions discussed above.

You MAY disclose my Personal Health information to:

(for example, list the name of spouse, partner, relative or

friends that we may disclose to)___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

You MAYNOT disclose my Personal Health information t

(specific names only)

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Please use this address for correspondence regarding my Personal Health Information (if different than the one listed on you

patient history form)

Street __________________________________________

City State Zip ___________________________________________

Printed Name Patient signature Date

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