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.

If you have any questions about this Notice please contact our office by calling 603-434-1577.

CHANGES TO THIS NOTICE: We are required to follow the privacy practices described in this Notice, although we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, the revised privacy practices will apply to all protected health information we already have about you, as well as any we receive or create about you in the future. If we do change our privacy practices and the terms of this Notice, we will post a new Notice at each of our offices and on our website at www.clmnh.org

OUR DUTY TO SAFEGUARD YOUR HEALTH INFORMATION: Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by or held by the Center for Life Management.

We are required by law to maintain the privacy of your health information, to provide you a description of our privacy practices, and to abide by the terms of this notice.

We are required to extend certain protections to your personal and medical information, know as “protected health information”, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your protected health information. Except in specified circumstances, we must use or disclose only the minimum necessary protected health information to accomplish the purpose of the use or disclosure.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION: We use and disclose protected health information for a variety of reasons. Federal law provides that we are permitted to make some uses/disclosures without your consent or authorization, primarily for treatment, payment, or agency operations. There are many situations, however, where the Center for Life Management will continue to require written authorizations. The Center for Life Management will no longer release or request “entire records” unless it is specifically justified. Areas where we are permitted to disclose protected health information without written authorization are:

  • For Treatment: We may disclose your protected health information to doctors, nurses, and other health care personnel who are involved in providing your health care, if you consent. For example, your protected health information will be shared among members of your treatment team, with our after hours answering service, or with your pharmacy staff. If it is necessary for your treatment, we may also share information with your other doctors, if you consent.
  • For Payment: We may use and disclose protected health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer, if you consent. Often we are required to give your insurance company information about your diagnosis and your treatment plan before they will pay us or reimburse you for the treatment. This may include reviewing services provided to you for medical necessity, and undertaking utilization review activities. Although sometimes the information is simple information, often your insurance company may need treatment plans and some specific treatment information before they will approve payment for services. The Center for Life Management makes every effort to only share the minimum necessary information.
  • For health care operations: We may use/disclose certain of your health information in the course of operating the Center for Life Management.


Some examples of instances where we may use and disclose certain protected health information:
  1. To business associates we have contracted with to perform the agreed upon service
  2. To remind you that you have an appointment for medical care, which may include leaving a message on an answering machine
  3. To assess your satisfaction with our services, which may include sending you mail
  4. To tell you about possible treatment alternatives
  5. To tell you about health–related benefits or services
  6. To contact you as part of fundraising efforts
  7. For conducting training, supervision or reviewing competence of our treatment staff.


If you do not wish to be on our mailing list, please fill out a Mailing List Exclusion Form at the site at which you are seen.

There are some services provided in our organization through contracts with business associates. Examples include our answering services, a transcription service, a records storage service, our legal advisors. When these services are contracted, we may disclose your protected health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information. Whenever an arrangement between the Center for Life Management and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

PERMITTED DISCLOSURES UNLESS YOU OBJECT: If you do not object, we may disclose some limited protected health information to family members or others involved in you care or payment for your care. For example, we may share information about your medications, appointments, diagnosis or potential for self-harm or information regarding services for payment purposes. We may also use or disclose your protected health information to notify or assist in notifying a family member or other person responsible for your care of your location and general conditions, or to an authorized entity assisting in a disaster relieve effort so you family can be notified of your location and general condition.

OTHER STATE AND FEDERAL LAW REQUIREMENTS: In situations where New Hampshire laws or other federal laws are more stringent or give you more rights than the federal privacy law, we will abide by the New Hampshire or other federal law. For example, HIV information is subject to greater protection under New Hampshire law and information about alcohol and drug abuse treatment is subject to more limited disclosure requirements under another federal law.

OTHER PERMITTED DISCLOSURES: For all other disclosures, we are required to have your written authorization, unless the use or disclosure fall within one of the exceptions described below.
  1. When required by law: We may disclose protected health information when a law requires us to do so, but only to the extent required by the law. For example, we must report information about suspected abuse or neglect of children and incapacitated adults or relating to certain suspected criminal activity, or in response to a court order. We must also disclose protected health information to authorities who monitor compliance with these privacy requirements.
  2. Public health activities: We may disclose protected health information to public health or other authorities charged with certain legal obligations, such as preventing or controlling disease, injury or disability.
  3. Health oversight activities: We may disclose protected health information to a health oversight agency for activities authorized by law, including audits, investigations and licensure. Please Note: We frequently share information with the NH Division of Behavioral Health. The NH Division of Behavioral Health closely oversees our operations and frequently reviews our records for service quality. The NH Division of Behavioral Health is also bound by confidentiality regulations.
  4. Threat to health or safety: To warn of a serious threat to a clearly identified or reasonably identifiable person, or a serious threat of substantial damage to real property, but only to the threatened person or law enforcement reasonably in a position to help prevent or lessen the treat.
  5. For specific government functions: We may disclose protected health information of military personnel in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons.
  6. Legal proceedings and law enforcement: We may disclose protected health information in response to an order of a court or administrative tribunal or limited protected health information to law enforcement regarding location of a suspect, fugit, material witness or missing person or which is evident of a crime on the premised of the Center for Life Management.
  7. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
  8. Workers’ compensation: Your protected health information may be disclosed by us as authorized by law to comply with workers’ compensation laws and other similar programs.


YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION: You have the following rights relating to your protected health information:
  1. Authorizations: For disclosures other than those listed above, we need your written authorization. You may revoke authorizations at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization. You will receive a copy of any authorization that you sign.
  2. Request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.
  3. To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.
  4. To inspect and copy your protected health information: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.
  5. To request amendment of your health information: If you believe that there is a mistake or missing information in our record, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the information is: (i) correct and complete; or (ii) not created by us and/or not part of our records. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your health information. If we approve the request for amendment, we will add an amendment to your protected health information and so inform you, and tell others that need to know about the amendment to your health information.
  6. To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your personal health information has been released other than instances of disclosure for treatment, payment or operations, to you or for which you gave consent, for national security purposes, to persons involved in your care or payment for your care, or made prior to April 14, 2003. We will respond to your written request for such a list generally within 60 days of receiving it. Your request can relate to disclosures going as far back as six (6) years, but not further than April 14, 2003. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.
  7. To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request.


COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with the Center for Life Management by calling the Privacy Officer at 603-434-1577 or with the US Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. The Center for Life Management will take no retaliatory action against you if you make complaints.

Effective Date: This Notice is effective as of April 14, 2003.