Notice of Patient Privacy Practices

This notice describes how medical information about you maybe used and disclosed and how you can get access to this information. Please review it carefully.

At Church Health we know that hope, health, and healing happen when we consider the whole person. That’s why we connect the dots across faith, medicine, movement, work, emotions, nutrition, and friends and family. Whether caring for our patients or reaching out to the community, we hold high the dignity and worth of each person. 

Notice of Privacy Practices for Protected Health Information


Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:

  • A nurse obtains treatment information about you and record sit in a health record.
  • During the course of your treatment, the physician determines he/she will need to consult with another provider in the area. He/she will share the information with such provider and obtain his/her input.

Example of use of your health information for payment purposes:

  • We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third-party payer.For example, we may need to give your insurance company information about your care, so they will pay us for the treatment.

Example of Use of Your Information for Health Care Operations:

  • We may perform internally or obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.

Health Information Rights

The health and billing records we maintain are the physical property of Church Health.

You have the following rights with respect to your Protected Health Information

  1. You have the right to get an electronic or paper copy of your medical record.
    • We will provide a copy or a summary of your health information, within 10 days of your request as required by law. We may charge a reasonable, cost-based fee.
  2. You have the right to ask us to correct or amend your medical record.
    • We may say ‘no’ to your request, but we will tell you why in writing within 60 days.
  3. You have the right to 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 say ‘yes’ to all reasonable requests.
  4. You have the right to ask us to limit what we use or share.
    • You can ask us to not use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say ‘no’ 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 with your health insurer. We will say ‘yes’ unless a law requires us to share that information.
  5. You have the right to get a list of those with whom we’ve shared information.
    • You can ask for a list (accounting) of times we’ve shared your health information for six years prior to the date you ask, who we share it with and why.
    • We will include all disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  6. You have the right to 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.
  7. You have the right to choose someone to act for you.
    • If you have given someone medical power of attorney, of if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
    • We will make sure the person has this authority and can act for you before we take any action.

If you want to exercise any of the above rights, please contact our Privacy Officer at 1350 Concourse Ave, Ste 142, Memphis TN 38104, in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

Church Health está obligado a:

  • Maintain the privacy of your protected health information as required by law;
  • Provide you with a copy of this Notice as to our duties and privacy practices as to the information we collect and maintain about you;
  • Abide by the terms of this Notice;
  • Notify you if we cannot accommodate a requested restriction or request;
  • Accommodate your reasonable requests regarding methods to communicate health information with you: and
  • Accommodate your request for an accounting of disclosures.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our Privacy Officer at 1350 Concourse Ave, Ste 142, Memphis TN 38104.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our Privacy Officer. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services (HHS).

  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of HHS as a condition of receiving treatment from the office.
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary of HHS.

Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule

Patient Contact

We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. We may contact you as part of a fund-raising effort.

Notification – Opportunity to Agree or Object

Unless you object we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family – Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

We may use and disclose your protected health information to assist in disaster relief efforts.

Opportunity to Agree or Object Not Required


Controlling Disease – As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Child Abuse & Neglect– We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

Food and Drug Administration (FDA) – We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.


We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.


Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.


We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.


We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.


We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.


Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.


We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.


To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.


We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.


Si usted es preso de una institución correccional, podemos divulgar a la institución o a sus agentes su información médica necesaria para su salud, la salud y la seguridad de otras personas


If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.


If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Other Uses and Disclosures

  • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
  • From time to time we will be giving tours to people who help us with our work or people who are interested in how we do our work. This may include donors, volunteers, students or others.
  • Church Health is financially supported by donations from individuals and organizations. We may contact you to raise funds to support the operations of Church Health.
  • Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or action has already been taken.


This Notice is posted on our web-site at

Effective Date: 4/13/2003

Reviewed: 1112/2011, 1/1012012, 1114/2015

Updated: 1/14/2013, 116/2016, 11/21/2016, 3/28/18, 8/22/19, 4/29/22

Privacy Officer Church Health

1350 Concourse Ave Ste 142
Memphis TN 38104


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