Your Information. Your Rights. Our Responsibilities.
This notice describes how Dragonfly Forward, LLC (“Dragonfly”) may use and disclose your protected health information and how you can get access to this information. Please review it carefully.
Here is a summary of this notice:
Your Rights
You have the right to:
• Get a copy of your paper or electronic health record
• Correct your paper or electronic health record
• Request confidential communication
• Ask us to limit the protected health information we share
• Get a list of those with whom we’ve shared your protected health 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 protected health information as we:
• Share information with your family and friends
• Market our services
• Raise funds
Our Uses and Disclosures
We may use and share your protected health information as we:
• Provide services to you
• Conduct our business operations
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
Here are more details:
Your Rights
When it comes to your protected 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 health record
• You can ask to see or get an electronic or paper copy of your health record and protected health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your protected health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your health record
• You can ask us to correct protected 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 protected 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. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared protected health information
• You can ask for a list (accounting) of the times we’ve shared your protected health information for 6 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 protected 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 using the information below.
• 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 protected health information, you can tell us your choices about what we share. If you have a clear preference for how we share your protected health information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
You have both the right and choice to tell us to share your protected health information with your family, close friends, or others involved in your care.
If you are not able to tell us your preference (for example if you are unconscious), we may go ahead and share your protected health information if we believe it is in your best interest. We may also share your protected health information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your protected health information unless you give us written permission:
• Marketing purposes
• 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 protected health information?
We typically use or share your protected health information in the following ways.
Provide services to you
We can use your protected health information to provide services to you and share it with other professionals who are treating you.
Example: We share information about you while coordinating the scheduling of your appointments with primary care and mental health providers.
Conduct our business operations
We can use and share your protected health information to conduct our business operations, improve your services, and contact you when necessary.
Example: We use health information about you to continuously improve the services we provide to you.
Bill for your services
We can use and share your protected 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 protected health information?
We are allowed or required to share your protected health 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 protected health 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 your protected health information for certain situations such as:
• Preventing disease
• Reporting suspected abuse, neglect, or domestic violence, including when reporting as a mandated reporter of child abuse or neglect under California law
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your protected health information for health research.
Comply with the law
We will share your protected health information 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 your protected health information:
• 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 or national security functions
Respond to lawsuits and legal actions
We can share your protected health information 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 protected health information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not sell your protected health information to data brokers or any other third parties that purchase protected health information.
• We will not use or share your protected health 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 see: 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 protected health information we have about you. The new notice will be available upon request, in our office, and on our website.
Effective Date
This notice is effective as of October 10, 2024
Contact Us
For any questions about this notice, please contact Michael Barrett, Dragonfly’s Privacy Officer, at
mbarrett@dragonflyforward.org.