Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing an acknowledgement. As provided in our notice, the terms of our notice may change, If we change our notice, you may obtain a revised copy.



We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. Each time you register at the FMC, we will offer you a copy of the current notice in effect.



If you believe your privacy rights have been violated, you may file a complaint with the FMC or with the Secretary of the Department of Health and Human Services You will not be penalized if you file a complaint. To file a complaint with the FMC, write to:

Dr. Amy Dawson, Medical Director


Cherise Dixie, MSW

Family Medicine Center

750 Broadway Suite 350

Fort Wayne, IN 46802



For more information on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) you may visit one of the following internet sites: http://www/



This is the notice required under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.



We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care and services you receive at Family Medicine Center(FMC). We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by FMC.



For treatment- We may disclose medical information about you to doctors, nurses, technicians, medical students, or other healthcare providers involved with your care, such as referral letters.

For payment- We may use and disclose medical information about you for payment purposes such as billing you or an insurance company, or for benefit determinations.

For Health Care Operations- We may use and disclose medical information about you for healthcare operations. These uses and disclosures are necessary to run the FMC and make sure that all of our patients receive quality care. We may remove information that identifies you from medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

For Appointment reminders- We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care at FMC.

For marketing- We will not release personally identifiable information for marketing purposes without your prior written authorization.

For research- Under certain circumstances, we may  use and disclose medical information about you for research purposes. Before we use or disclose medical information for research, the project will have been approved by the Director of the FMC. We will not release personally identifiable medical information without your written authorization.

As required by the law-We will disclose medical information about you when required or permitted to do so by federal, state, or local law, such as by court order, public health issue, or other required disclosures.

To avert a serious threat to health or safety- We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure will only be made to someone able to help prevent the threat.



Right to inspect- Your health information records belong to FMC. You do have the right, however, to inspect and purchase a copy of your records. Once we or any other healthcare providers providing you treatment enter information on your record, it may not be changed. If you disagree with any of the information recorded you may submit a written clarifying statement to supplement your record.

Right to request restrictions- You may ask that we restrict our uses of your records. We do not have to accept the restrictions if we are complying with the law.

Right to request confidential communication- You may request that we contact you by means other than phone or mail. We will comply if possible.

Right to a list of disclosures- You may ask for a list of disclosures we made other than for treatment, payment, or healthcare operations (above)