Effective Date: September 27, 2025
Practice: Ally4Health
Address: 25010 US Hwy 27, Suite I, Leesburg, FL 34748
Phone: 352-250-9819 • Email: info@ally4health.com
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.
Our Responsibilities
- Maintain the privacy and security of your protected health information (“PHI”).
- Provide you with this Notice and follow the duties and privacy practices described here.
- Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
- Abide by HIPAA, HITECH, and applicable Florida law. Where laws conflict, we follow the rule providing greater protection.
We may change this Notice at any time. The updated Notice will apply to existing and future PHI and will be posted on our website and available at our office. The Effective Date above tells you when it last changed.
How We May Use and Disclose Your PHI
Treatment
To provide, coordinate, or manage your care and related services. Example: Sharing information with other clinicians involved in your treatment.
Payment
To bill and receive payment for services you receive. Example: Sending information to your health plan for prior authorization or reimbursement.
Health Care Operations
For operations such as quality assessment, training, licensing, audits, and administrative purposes. Example: Reviewing records to improve clinical quality.
Other uses and disclosures permitted or required by law
- Public Health and Safety: Reporting certain diseases, adverse events, product issues; preventing or reducing a serious threat.
- Health Oversight: Audits, inspections, or investigations by regulators.
- Judicial/Administrative Proceedings: In response to a court order or lawful subpoena with required safeguards.
- Law Enforcement: For limited purposes as permitted by law.
- Decedents: To coroners, medical examiners, or funeral directors.
- Organ/Tissue Donation: To facilitate donation and transplantation.
- Research: Under specific conditions and approvals that protect your privacy.
- Workers’ Compensation & Similar Programs: As authorized to provide benefits for work-related injuries or illness.
- Specialized Government Functions: National security, protective services, correctional institutions (as applicable).
- As Required by Law: When other laws mandate disclosure.
Business Associates
We may disclose PHI to contractors who perform services for us (e.g., billing, IT, cloud services) under written agreements requiring safeguards.
Individuals Involved in Your Care
With your permission or as allowed by law, we may share limited information with a person involved in your care or payment for care, or to notify a family member about your location and general condition.
Uses and Disclosures Requiring Your Authorization
We will obtain your written authorization for uses and disclosures not described in this Notice or otherwise permitted by law, including:
- Most uses and disclosures of psychotherapy notes (if any).
- Most uses and disclosures of PHI for marketing purposes.
- Any sale of PHI.
You may revoke an authorization at any time by writing to us at the contact listed below. Revocation does not affect information already used or disclosed in reliance on your authorization.
Your Rights
Right to Inspect and Obtain a Copy
You may see and get a copy of your medical record (including electronic copies) in the format you request if readily producible. We may charge a reasonable, cost-based fee as allowed by law. We will provide access within legally required timeframes.
Right to Request an Amendment
If you believe your record is incorrect or incomplete, you may request an amendment. We may deny your request in certain circumstances, but we will tell you why in writing and how to appeal.
Right to an Accounting of Disclosures
You may request a list (“accounting”) of certain disclosures of your PHI made in the past six (6) years, excluding those for treatment, payment, health care operations, and other disclosures exempted by law.
Right to Request Restrictions
You may request restrictions on how we use or disclose your PHI. We are not required to agree except in one case: if you pay for a service in full out-of-pocket, you may request that we not share information about that service with your health plan for payment or operations, and we must agree unless disclosure is required by law.
Right to Request Confidential Communications
You may request we contact you in a specific way (for example, at a certain phone number or address) or send mail to a different address. We will accommodate reasonable requests.
Right to Receive a Paper or Electronic Copy of This Notice
You can request a paper copy of this Notice at any time, even if you agreed to receive it electronically. The latest version is also available on our website.
Right to Choose a Personal Representative
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 to the extent allowed by law.
Your Choices
For certain 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 below, please tell us:
- Sharing information with family, friends, or others involved in your care.
- Sharing information for disaster relief.
- Using your information for limited marketing (e.g., appointment reminders or general wellness materials).
If you cannot tell us your preference (for example, if you are unconscious), we may share information if we believe it is in your best interest and permitted by law.
Complaints and Questions
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services (HHS), Office for Civil Rights. We will not retaliate against you for filing a complaint.
To contact us about privacy matters or to file a complaint:
Privacy Officer: Ally4Health Privacy Officer
Ally4Health • 25010 US Hwy 27, Suite I, Leesburg, FL 34748
Phone: 352-250-9819 • Email: info@ally4health.com
To file a complaint with HHS OCR:
Visit hhs.gov/ocr/privacy/hipaa/complaints/ or mail your complaint to the appropriate regional office listed on that page.
Acknowledgment of Receipt (For Your Intake Workflow)
You may include the following acknowledgment in your intake forms or e-signature flow:
I acknowledge that I received or was offered a copy of Ally4Health’s Notice of Privacy Practices.
Patient/Representative Name: __________________________
Signature: __________________________ Date: __________
Relationship (if not patient): __________________________