This Notice describes how Personal Health Information (PHI) about you may be used and disclosed and how you can get access to this information. The purpose of this Notice is to provide you with the information you are entitled to under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Please review this Notice carefully. If you have any questions about this Notice, please contact Reflections Wellness Center LLC at firstname.lastname@example.org
WHO WILL FOLLOW THIS NOTICE?
This Notice describes Reflections’ privacy practices and that of:
· Any physician or health care professional authorized to enter information into your medical chart.
· All departments and units of our facility.
· All employees, staff, interns, and other office personnel.
All these individuals, sites and locations follow the terms of this Notice. In addition, these individuals, sites and locations may share PHI with each other or with third party specialists for treatment, payment or office operations purposes described in this Notice.
OUR PLEDGE REGARDING PHI
We understand that PHI about you and your health is personal. We are committed to protecting your PHI. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records of your care generated by our facility.
This Notice will tell you about the ways in which we may use and disclose PHI about you. We also describe your rights and certain obligations we have regarding the use and disclosure of PHI.
We are required by law to:
• Maintain the privacy of your PHI;
• Provide you this Notice of our legal duties and privacy practices with respect to your PHI;
• Follow the terms of this Notice;
• Notify you if we are unable to agree to a requested restriction; and
• Accommodate reasonable requests.
The main reasons we use and disclose your PHI are to evaluate and process any requests for coverage and claims for benefits you may make, or in connection with other health-related benefits or services that may interest you. The following describes these and other use and disclosures, together with some examples:
For Treatment. We may use PHI about you to provide you with medical treatment or services. We may disclose PHI about you to the facility's office personnel who are involved in taking care of you at the facility or elsewhere. We also may disclose PHI about you to people outside our facility who may be involved in your care after you leave the facility, such as family members or others we use to provide services that are part of your care, provided you have consented to such disclosure. These entities include third-party physicians, hospitals, nursing homes, pharmacies or clinical labs with whom we consult or makes referrals.
For Payment. We may use and disclose PHI about you so that the treatment and services you receive at our office may be billed to and payment may be collected from you, an insurance company or third parties such as credit card entities, banks, and financing companies. For example, we may need to give your health plan information about procedures you receive at Reflections, so they will pay us or reimburse you for the services. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose PHI about you for our health care operations. This use and disclosure are necessary to run our facility and make sure that all our clients receive quality care. For example, we may use PHI about you to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine PHI about many clients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to our physicians, staff and other office personnel for review and learning purposes.
Individuals Involved in Your Care or Payment for Your Care. We may release PHI about you to a friend or family member who is involved in your medical care, or who helps pay for your care, provided you have consented to such disclosure.
Where Required by Law or for Public Health Activities. We disclose PHI when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding communicable diseases or providing PHI to a governmental agency or regulator with health care regulatory and oversight responsibilities. We may also release PHI to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.
To Avert a Serious Threat to Health or Safety. We may disclose PHI to avert a serious threat to someone's health or safety. We may also disclose PHI to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations, and so that your family can be notified about your condition, status and location.
For Health-Related Benefits or Services. We may use PHI to provide you with information about benefits available to you under your current coverage or policy and in limited situations, about health-related products or services that may be of interest to you.
For Law Enforcement or Other Government Functions. We may disclose PHI in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose PHI about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
When Requested as Part of a Regulatory or Legal Proceeding. If you or your estate is involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the PHI requested. We may disclose PHI to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.
Disclosures of Workers' Compensation. We may, without your authorization, disclose information in your Medical Record to the extent that disclosure is authorized by, and necessary to comply with, laws relating to workers' compensation and other similarly established programs.
Abuse or Neglect. We believe abuse or neglect is a serious issue. We may disclose your PHI to a public health authority authorized to receive reports of abuse or neglect. We may also disclose your information if, in our best judgment, we believe you have been a victim of abuse, neglect or domestic violence. When disclosing PHI in abuse or neglect cases, we will follow applicable federal, state and local laws.
Research and Health Oversight. We are permitted to disclose your PHI to researchers when an institutional review board that has reviewed the research proposal, as well as established protocols to ensure the privacy of your information has approved their research. We are permitted to disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
Military Activity and National Security. We are permitted to use or disclose PHI of individuals who are Armed Forces personnel under the following circumstances: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We are also permitted to disclose your information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required Notices of unauthorized access to or disclosure of your health information.
Inmates or Individuals in Custody. If you are under the custody of law enforcement or an inmate of a correctional institution, we may release PHI to a law enforcement officer or correctional institution, so they can: (1) provide you with health care; (2) protect your health and safety or that of others; or (3) maintain the safety and security of the law enforcement facility or correctional institution.
Other Uses of PHI. Other uses and disclosures of PHI not covered by this Notice and permitted by laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose PHI about you, you or your legal representative may revoke that authorization in writing, at any time, except to the extent that we have acted relying on the authorization or if the authorization was obtained as a condition of obtaining your health insurance coverage. You should understand that we cannot take back any disclosures we have already made with authorization.
YOUR RIGHTS REGARDING PHI WE MAINTAIN ABOUT YOU
The following are your various rights as a consumer under HIPAA concerning your PHI:
Right to Inspect and Copy Your PHI. In most cases, you, or your authorized representative, (hereafter, you will be used to incorporate both you and your authorized representative, if you have one), have the right to inspect and obtain a copy of the PHI that we maintain about you. To inspect and copy PHI, you must submit a written request to Reflections. We normally respond to your request within 30 days of receipt. If we are unable to respond within 30 days of receipt, we will notify you in writing why we are unable to respond and the date by which we will respond. In no case will our response be given later than 30 days after the expiration of the date that it would have been due had we not given Notice.
To receive a copy of your PHI, you may be charged a fee (as permitted by federal, state or local law) for the costs associated with your request; but, certain types of PHI will not be made available for inspection and copying, including psychotherapy notes and PHI collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding or laboratory results that are subject to laws that prohibits access. In limited circumstances we may deny your request to inspect and obtain a copy of your PHI or we may deny your request with respect to only some of the information in your Medical Record. If your request is denied, you will be notified in writing why we denied the request and explain your rights to request a review of that denial and how to exercise those rights. Finally, we will also advise you how you may make a complaint to us or to the Secretary of the Department of Health and Human Services. If your request is denied only in part, we will provide you with access to the remaining information in your Medical Record. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review.
Right to Amend Your PHI. If you believe that your PHI is incorrect, or an important part is missing, you have the right to ask us to amend your PHI while it is kept by or for us. You must make a written request and your reason to amend your PHI to Reflections. We may deny your request if it is not in writing or does not include a supporting reason. We may deny your request if you ask us to amend PHI that: is accurate and complete; was not created by us unless the person or entity that created the PHI is no longer available to make the amendment; is not part of the PHI kept by or for us; or is not part of the PHI which you would be permitted to inspect and copy. Our response process and the compliant procedure as the same as detailed above for accessing your records.
Right to an Accounting of Disclosures. You have the right to request a list of the disclosures we have made of PHI about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel, or made pursuant to your authorization or made directly to you. To request this accounting, you must submit your request in writing to Reflections. Your request must state the period from which you want to receive a list of disclosures. The period may not be longer than six years and may not include dates before March 15, 2017, the start of Reflections Wellness Center LLC. Your request should indicate in what form you want the accounting (paper or electronically). We will respond to your request for an accounting within 60 days after receipt unless we notify you in writing prior to the expiration of the 60-day period why we are unable to respond within that time frame and specify the date on which we will respond, which will not be later than 90 days after receipt of your request. The first accounting you request within a 12-month period will be free. We may charge you for responding to any additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on PHI we use or disclose about you for: 1) treatment, payment or health care operations; or 2) that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend; or 3) for notification purposes as described in this Notice of Privacy Practices. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request once your account has been paid in full and the terms of the following section “Out-of-Pocket Payments” are met. To request a restriction, you must make your request in writing to Reflections. Your request must include (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on PHI uses or disclosures that are legally required, or which are necessary to administer our business.
Out-of-Pocket-Payments. If you paid out-of-pocket at the self-pay rate and requested that we not bill your health plan for a specific service, you have the right to ask that your PHI with respect to that service not be disclosed to your health plan for purposes of payment, and we will honor that request.
Right to Request Confidential Communication. You have the right to request how we communicate PHI with you. For example, you can ask that we only contact you by mail. To request confidential communications, you must make a written request to Reflections and specify how or where you wish to be contacted. We accommodate all reasonable requests.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or with the Agency for Health Care Administration. To file a complaint with us, please contact us at email@example.com. All complaints must be submitted in writing. You will not be penalized for filing a complaint. If you have questions as to how to file a complaint, please contact Reflections at the address above.
Changes to This Notice. We reserve the right to change the terms of this Notice at any time. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as any PHI we receive in the future. If we do make such changes, we will post a copy of the revised Notice in the reception area of all our facilities and in other areas of our facilities where we provide health care services and on our website. You may obtain a copy of the current Notice by emailing firstname.lastname@example.org.