Privacy Policy

Notice of Privacy Practices

Your Information. Your Rights. Our Responsibility.

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.


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. You have the right to:


  • Get an electronic or paper copy of your medical records:   You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within thirty (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. Ask us how to do this. We may deny your request, but we will explain why and next steps in writing within sixty (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. We will say “yes” unless a law requires us to share that information.
  • Get a list of those with whom we have shared information: You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all of 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 will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within twelve (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 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 have been violated: You can complain if you feel we have violated your rights by contacting us using the information on page 5. 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 We will not retaliate against you for filing a complaint.

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. Tell us what you want to do, and we will follow your instructions.

In these circumstances, you have both the right and choice to tell us to:

  • Share your information with your family, close friends, or others involved in your care;
  • Share information in a disaster relief situation;
  • Include your information in a hospital directory; and/or

If you are unable to tell us your preference, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health and safety.

In these circumstances we never share your information unless you give us written permission:

  • Marketing purposes;
  • Sale of your information; and
  • Sharing of psychotherapy notes

In the circumstance 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 health information?
We typically use or share your health information in the following ways:

    1. Help manage the health care treatment you receive – We can use your health information and share it with other professionals who are treating you.
    • Example: A doctor treating you sends us information about your diagnosis and treatment plan so we can arrange additional services. 
    2. Run our organization – We can use and disclose your information to run our organization, improve your care, and contact you when necessary. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long-term care plans.
    • Example: We use health information about you to develop better services for you. 
    3. Pay for your health services – We can use and disclose your health information as we pay for your health services.
    • Example: We share information about you with your dental plan to coordinate payment for your dental work. 
    4. Administer your plan – We may disclose your health information to your health plan sponsor for plan administration.
    • Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. 

    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 must meet many conditions in the law before we can share your information for these purposes.

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

    2. Do research – We can use or share your information for health research.

    3. Comply with the law – We will share information about you if state or federal laws so require, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

    4. Respond to organ and tissue donation requests and work with a medical examiner or funeral director – We can share health information about you with organ procurement organizations, and can share health information with a coroner, medical examiner, or funeral director when an individual dies.

    5. 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, and for special government functions such as military, national security, and presidential protective services.

    6. 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.

    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 we receive your written permission. 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:

    Changes to the Terms of this Notice

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website: ___________________.

    Contact Information

    If you have any questions about this notice, please contact us at:

    Health and Wellness of Carmel, LLC
    Attn: John Compton
    11900 N. Pennsylvania Street, Suite 200
    Carmel, Indiana 46032

    This notice is effective 06/01/2023.

    Notice to Patient:

    Health and Wellness of Carmel, LLC (the “Practice”) is required to provide you with a copy of our Notice of Privacy Practices, which states how the Practice may use and/or disclose your health information. Please sign this form to acknowledge receipt of the notice. You may refuse to sign this acknowledgement if you wish.