Notice of Privacy Practices

Effective Date: August 26, 2024 | Last updated, June 23, 2026

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.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION 

The privacy of your medical information is important to us. The Dorm understands that your medical information is personal, and The Dorm is committed to protecting it. The Dorm creates a record of the care and services you receive at our organization. The Dorm needs this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways The Dorm may use and share medical information about you. The Dorm also describes your rights and certain duties The Dorm has regarding the use and disclosure of medical information. 

2. OUR RIGHTS  

The Dorm is a HIPAA-covered entity. The Dorm will maintain the privacy of your medical information and follow all applicable privacy laws. 

The Dorm has the right to: 

  1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 
  2. Make the changes in our privacy practice and the new terms of our notice effective for all medical information that The Dorm keeps, including information previously created or received before the changes. 

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION 

The following section describes the different ways that The Dorm uses and discloses medical information. Not every use or disclosure will be listed. However, The Dorm has listed the different ways we are permitted to use and disclose medical information without your specific written authorization and will obtain written authorization for other uses. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the bottom of this notice.

FOR TREATMENT: The Dorm may use medical information about you to provide you with medical treatment or services. The Dorm may also share medical information about you with your other third party health care providers, for example, your primary care physician or therapist, to assist them in treating you.

FOR PAYMENT: The Dorm may use and disclose your medical information for payment purposes. A bill may be sent to you, a third-party payer, or someone else who pays your bill, for example, your Sponsor. The information on or accompanying the bill may include your medical information. 

FOR HEALTH CARE OPERATIONS: The Dorm may use and disclose your medical information for our health care operations. For example, this may include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses, and credentials The Dorm needs to serve you. 

ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health care operations, The Dorm may use and disclose medical information for the following purposes;

WE ARE REQUIRED TO:

We are required by law to maintain the privacy of records, to provide you with notice of our legal duties and privacy practices with respect to records, and to notify affected patients following a breach of unsecured records;

We are required to abide by the terms of the notice currently in effect; and

We reserve the right to change the terms of our notice and to make the new notice provisions effective for records that it maintains. We will provide patients with a revised notice, on our website.

We are required by law to maintain the privacy of records, to provide patients with notice of its legal duties and privacy practices with respect to records, and to notify affected patients following a breach of unsecured records;

We are required to abide by the terms of the notice currently in effect; and

  • NOTIFICATION: The Dorm may use and disclose medical information to notify or help notify: a family member, your personal representative, or another person responsible for your care. The Dorm will share information about your location, general condition, or death. If you are present, The Dorm will get your permission if possible before The Dorm shares or gives you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, The Dorm will share only the health information that is directly necessary for your health care, according to our professional judgment. 
  • RESEARCH IN LIMITED CIRCUMSTANCES: The Dorm may use medical information for research purposes where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information. 
  • COURT ORDERS AND JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: The Dorm may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, The Dorm may share your medical information with law enforcement officials. 
  • PUBLIC HEALTH ACTIVITIES: As required by law, The Dorm may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, including child abuse or neglect. The Dorm may also, when authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition. 
  • VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE OR RELEASE TO LAW ENFORCEMENT: The Dorm may use and disclose medical information to appropriate authorities if The Dorm reasonably believes that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. The Dorm may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. The Dorm may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody. 
  • HEALTH OVERSIGHT ACTIVITIES: The Dorm may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities. 
  • REPORTING TO LAW ENFORCEMENT: Under certain circumstances, The Dorm may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies. 
  • APPOINTMENT REMINDERS: The Dorm may use and disclose medical information for purposes of sending you appointment confirmations or otherwise reminding you of your appointments. 
  • ALTERNATIVE AND ADDITIONAL MEDICAL SERVICES: The Dorm may use and disclose medical information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives. 

4. YOUR INDIVIDUAL RIGHTS 

You may: 

  1. Look at or get copies of certain parts of your medical information. You must make your request in writing by sending a letter or email to the contact listed at the end of this notice. If you request copies, The Dorm will charge you a fee for the costs of copying, mailing, or other supplies associated with your request. Under limited circumstances, The Dorm may deny you access to your records. 
  2. Request that The Dorm place additional restrictions on our use or disclosure of your medical information. The Dorm is not required to agree to these additional restrictions, but if The Dorm does, The Dorm will abide by our agreement (except in the case of an emergency). 
  3. Request that The Dorm communicate with you about your medical information by different means or at different locations. Your request that The Dorm communicate your medical information to you by different means or at different locations must be made in writing to the contact listed at the bottom of this notice. 
  4. Request that The Dorm change certain parts of your medical information. The Dorm may deny your request if The Dorm did not create the information you want changed or for certain other reasons. If The Dorm denies your request, The Dorm will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information you want changed. If The Dorm accepts your request to change the information, The Dorm will make reasonable efforts to inform others, including people you name, of the change and to include the changes in any future sharing of that information. 
  5. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact listed at the end of this notice.

QUESTIONS AND COMPLAINTS 

If you have any questions about this notice or if you think that The Dorm may have violated your privacy rights, please contact us at [email protected]. You may contact us to submit a complaint or submit requests involving any of your rights in Section 4 of this notice by writing to the following address: 

The Dorm
1814 N St NW
Washington, DC 20036

ATTN: The Dorm Site Director – [email protected]

You may also submit a written complaint to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. The Dorm will not retaliate in any way if you choose to file a complaint.

PRIVACY PRACTICES ACKNOWLEDGEMENT

ACKNOWLEDGEMENT FORM 

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. 

Name (Print)_____________________________________________Birthdate__________
Signature_______________________________________________________
Date______________________________________________________________

OFFICE USE ONLY

I attempted to obtain the patient’s signature on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: 

Date:
Initials:
Reason: 

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