Notice of Privacy Practices

Amplify Wellness & Performance, LLC

Effective Date: May 1, 2025

Your Information. Your Rights. Our Responsibilities.

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.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
  • We will provide a copy or a summary of your health information, usually within 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.
  • We may decline 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 accommodate 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 decline 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 payment purposes or our operations with your health insurer.
    • We will agree unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can request a list (accounting) of the times we’ve shared your health information for six years prior to your request, including who we shared it with and why.
  • We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures.
  • We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee for additional requests 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 health information.
  • We will verify that the person has this authority before taking 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 our Privacy Officer at Email: sharon@amplifyingperformance.com  Phone: 978-337-6095.
  • 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
    • Visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
    • 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, please inform us about what you want us to do, and we will follow your instructions.

You have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

If you are unable to tell us your preference (for example, if you are unconscious), 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 or safety.

We never share your information for the following purposes without your written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

Fundraising

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How we typically use or share your health information:

To treat you

  • We can use your health information and share it with other professionals who are treating you.
  • Example: A doctor treating you for an injury asks another doctor about your overall health condition.

To run our organization

  • We can use and share your health information to run our practice, improve your care, and contact you when necessary.
  • Example: We use health information about you to manage your treatment and services.

To bill for your services

  • We can use and share your 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 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.

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
  • Preventing or reducing a serious threat to anyone’s health or safety

Research

  • We can use or share your information for health research.

Comply with the law

  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services.

Respond to organ and tissue donation requests

  • We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

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
  • For special government functions such as military, national security, and presidential protective services

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 notify you 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 you tell us we can in writing. If you tell us we can, you may change your mind at any time by letting us know in writing.

For more information: 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 information we have about you. The new notice will be available upon request, in our office, and on our website.

Contact Information

Privacy Officer: Sharon A. Chirban, PhD
Email: sharon@amplifyingperformance.com
Phone: 978-337-6095
Address: 364 Boylston Street, Boston, MA 02465

Last Updated: May 1, 2025

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