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Notice of Patient Privacy Practices


Please review the following notice that describes how medical information about you may be used and disclosed and how you may get access to this information. PLEASE READ IT CAREFULLY.

This notice is provided on behalf of the Community Clinic.

Effective Date: September 23, 2013


This notice of privacy practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes permitted or required by law. “Protected health information” or “PHI” is information that may identify the patient and that relates to the patient’s past, present or future physical or mental health, and may include name, address, phone numbers and other identifying information. We will not use or disclose PHI of a person served except as stated in this Notice of Privacy Practices. Any amendments to this Notice will apply retroactively to PHI maintained prior to the date of the amendment.

We are required to give you this notice and to maintain the privacy of your protected health information. We must abide by this notice, but we reserve the right to change the privacy practices described in it. A current version of this notice with required revisions, if any, may be obtained by sending a written, request to the Community Clinic, HIPAA Officer, 614 E Emma Ave. Suite 300, Springdale AR 72764.

We understand that medical information about you and your health is personal and confidential and we are committed to protecting the confidentiality of your medical information. We create a record of the care and services you receive. We need this record to provide services to you and to comply with certain legal requirements. This notice will tell you about the ways we may use and disclose your information. We also describe your rights and certain obligations we have to use and disclose your health information.

If you believe your privacy rights have been violated, you may complain to us or to the US Secretary of Health and Human Services. To file a complaint with us you may send a letter describing the violation to the clinic HIPAA Officer. There will be no retaliation for filing a complaint.

If you have questions or need more information, contact the clinic HIPAA Officer at 479-751-7417.


This notice describes the practices of the Community Clinic health care professionals, employees, volunteers and others who work in provide health care services.


Disclosure of your health information by us
We may use or disclose your protected health information for purposes of treatment, payment or health care operations without your consent or authorization. This information may be transmitted by electronic transmission, by fax transmittal or by e-mail. Treatment “Treatment” is defined by the Department of Health and Human Services in its Privacy Standards as “…provisions, coordination, or providers…” This means that for our own purposes we may use or disclose protected health care information among our employees and other staff professionals of the Clinic for the purpose of treating your medical condition. Furthermore, we may disclose your protected health information to other health care providers if we make a referral, if we seek consultation or review by another health care provider, or if they are directly involved in your care. Payment “Payment” can refer to several things. An example of a “disclosure or use of protected health care information” for payment purposes would be submitting a claim to your insurance carrier so as to be reimbursed for our services. Other examples include activities such as determining eligibility of coverage under your insurance plan or answering questions by your insurance company to determine if there is a medical necessity for the procedure or diagnosis. Health Care Operations The final category under which we may use or disclose your protected health information without your permission is for “health care operations”. This category includes a wide range of day-to-day activities performed by us such as quality assessment, care coordination, contacting other providers about care alternatives for you, conducting internal training programs for supervisory purposes, and activities associated with the licensing and issuance of credentials for our staff.


We will issue appointment reminders, provide follow-up information on treatment alternative, and possibly offer other treatment-related services to you. Typically, we conduct these contacts by mail or by phone. If you do NOT wish us to leave messages on your telephone answering machine or to receive mail at your residence, contact us. You do have the right to ask us to contact you in a confidential manner and we will do our best to accommodate you. We may also contact you for fundraising purposes, though you have the right to opt out of receiving such communications.


You will be asked to sign an authorization if you wish us to disclose your protected health information to others and the disclosure is for something other than payment, treatment or health care operations. You will always have the right to revoke an authorization at any time, except to the extent this Clinic or any other providers have already taken an action in reliance upon your authorization.


Under Arkansas law, there are specific conditions or events that must be disclosed to third parties or state agencies whether or not you authorize this use or disclosure.

These categories include:
Incidents of suspected child abuse or neglect.
Reportable communicable disease such as HIV or other STDs
Sexual assaults
Knife or gunshot wounds
Domestic violence
Sudden death of a child
Legal proceedings or law enforcement

In addition, the Clinic participates in clinical research studies, which may involve your treatment. From time to time, we review our patient’s protected health information to determine if they are suitable candidates to participate in clinical research trials. Before we will enroll you in such a research program or disclose your protected health information to third parties conducting research trials, we will obtain your express authorization.


You have the following rights relating to your protected health information and may:

Obtain a current paper copy of this notice.

Inspect or obtain a copy of your records. Your request to obtain a copy of your medical records must be in writing. You may be charged a fee for the cost of copying, mailing or other supplies. We are allowed to deny this request under certain circumstances. In some situations, you have the right to have the denial of your request reviewed by a licensed health care professional identified by the Community Clinic who was not involved in the original denial decision. We will comply with the outcome of this review.

Request that we amend your record, if you feel that the information is incomplete or incorrect.

Request in writing that a restriction on certain uses and disclosure of your information, such as restricting disclosures to your health plan in instances when you have paid for health care items or services in full.

Obtain a record of certain disclosures of your protected health information.

Make a reasonable request to have confidential communication of your

protected health information sent to you by alternative means or at alternative locations.

We will obtain your written permission for uses and disclosures of your protected health information (which may include most uses and disclosures of behavioral health notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI) that are not covered by the notice or permitted by law. Except to the extent that the use or disclosures has already occurred, you may cancel this permission. This request to cancel must be put in writing. Submit any written requests to inspect, copy or amend your records to the Medical Records department.


We are required to protect the privacy of your protected health information, abide by the terms of this notice, make the notice available to you, notify you if we are unable to agree with a requested restriction or an alternative means of communicating, and notify you following any breach of your unsecured PHI.

For an Appointment, Call or Text 1-855-438-2280 or Book Online

Community Clinic accepts cash, check, major credit cards, ARKids First, Medicaid, Medicare, Arkansas Health Insurance Marketplace Plans and most private insurance plans. We have bilingual staff to help with on-site enrollment to ARKids First, Medicaid and the Arkansas Health Insurance Marketplace. A discount program is available for those patients who qualify based on income.