Our Pledge Regarding Protected Health Information

We are committed to protecting your Protected Health Information ("PHI"). We are required by law to make sure that PHI that identifies you is kept private; to notify affected individuals following a breach of unsecured PHI; to provide you this Notice of our legal duties and privacy practices with respect to your PHI; and to follow the terms and provisions of this notice. We reserve the right to change this Notice at any time, and we reserve the right to make the revised Notice effective for PHI we have about you as well as any PHI we receive in the future. A copy of the current Notice is posted in the waiting area and is available at the check in desk at each facility.

Who Will Follow This Notice

This Notice applies to all PHI received or generated by Concord Imaging Center, LLC ("CIC") and the physician and support personnel engaged by CIC.

Other physicians and healthcare providers may have different policies and notices regarding PHI received or generated by them. We will share PHI with other healthcare providers and their Business Associates for the purposes of providing healthcare treatment and related services to you, billing and being paid for such services and conducting our healthcare and business operations, internally and with Business Associates.

Limitations on the Applicaiton of the Notice

This Notice does not apply to any health information which has been "de-identified." De-identified health information is information that does not identify you personally and could not reasonably be attributed to you.


How We May Use and Disclose Your Health Information

The following categories describe different ways that we use and disclose health information:

For Treatment. We may use your PHI to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, or other healthcare personnel who are involved in your care. For example, we may use your medical history to assess your health in order to perform the requested radiology procedure.

For Payment. We may use and disclose PHI about you so that the treatment and services you receive may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a radiology exam you received at the imaging center so your health plan will pay us or reimburse you for the exam. We may also tell your health plan about a procedure you are going to have performed so that we may obtain prior approval or to determine whether your plan will cover the procedure.

For Health Care Operations. We may use and disclose your PHI as necessary to conduct the healthcare and business operations of CIC, internally and with Business Associates. We may use your PHI, for example, in reviewing our provision of healthcare services and evaluating the performance of our staff in caring for you.

Other Uses of Health Information. We may use and disclose PHI to contact you to remind you of an appointment for treatment or care at the imaging center.


We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives.

We may release PHI, with your authorization, to a friend or family member who is involved in your medical care or to someone who helps pay for your care.

We may use and disclose your PHI for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your PHI to prepare or analyze a research protocol and for other research purposes.

We may release PHI to businesses that use your health information to assist us in performing essential healthcare operations, payment and other functions. Contracts with these businesses must include specific provisions governing the use and protection of your information as required by federal law.

We may disclose PHI to a health oversight agency for activities required by law. These oversight activities include audits, investigations, inspections and licensure.

We will disclose your PHI when required to do so by federal, state or local law; for example, in response to a court order, subpoena, warrant or similar process.

We may use and disclose your PHI when necessary to prevent a serious threat to you, another person or the public.

We may disclose your PHI for public health activities. For example, to prevent or control disease, to report child/domestic/elder abuse or neglect, to report reactions to medications or problems with products, or to notify you of recalls.

We may release PHI to organizations, if you are an organ donor, to facilitate organ or tissue donation and transplantation.

We may release PHI to a coroner or medical examiner. Such disclosure may be necessary to identify a deceased person or determine the cause of death. We may also release PHI to funeral directors as necessary to carry out their duties.

We may release PHI about you to your employer for workers' compensation purposes.

We may release your PHI as required by military command authorities, if you are a member of the Armed Forces. We also may release PHI about foreign military personnel to the appropriate foreign military authority.

We may release your PHI to authorized federal officials to provide protection to the President of the United States, other authorized persons or foreign heads of state or conduct special investigations for intelligence, counterintelligence and other national security activities as authorized by law.

If you are an inmate or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. We are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.


Your Rights Regarding Your Protected Health Information

Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care. You must submit your request in writing to Concord Imaging Center. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy records in certain, very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

Right to Amend. If you feel that your PHI is incorrect or incomplete, you may ask us to amend the information. Your request must be made in writing and submitted to Concord Imaging Center. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may deny your request if you ask us to amend information that:

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" of your health information if any such disclosure was made for any purpose other than for treatment, payment or healthcare operations, or in a response to an authorization signed by you. To request this list or accounting of disclosures, you must submit your request in writing to Concord Imaging Center. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the health 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.

Right to 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. For example, you can ask that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. Paper copies are available at the check in desk. You may request a copy of this notice at any time.

To exercise any of your rights, please contact us in writing at Concord Imaging Center 248 Pleasant Street, Concord, NH 03301.



If you believe your privacy rights have been violated, you may file a complaint with the imaging center. Please contact:

Concord Imaging Center
248 Pleasant St • Concord, NH 03301
(603) 225-0425

If you believe your privacy rights have been violated, you may contact the Secretary of the Department of Health and Human Services, at 200 Independence Avenue SW Room 509F, HHH Building, Washington, D.C. 20201 (email: ocrmail@hhs.gov). You will not be penalized for filing a complaint.

To obtain more information concerning this Notice of Privacy Practices, you may contact our Privacy Officer at (603) 225-0425.