HIPAA NOTICE OF PRIVACY PRACTICES
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 “Privacy Officer” at email@example.com or at 617-531-9149.
GOOD MEASURES PLEDGE REGARDING PROTECTED HEALTH INFORMATION:
Good Measures is required by federal and state law to maintain the privacy of your individually identifiable medical and health information (“Protected Health Information”), and to provide you with a copy of this Notice, which describes our privacy practices regarding Protected Health Information. We understand that information about you and your health is personal, and we are committed to safeguarding Protected Health Information. This Notice applies to all of the records of your care generated by Good Measures. This Notice will tell you about the ways in which we may use and disclose Protected Health Information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your Protected Health Information.
We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all Protected Health Information that we maintain by: • sharing the revised Notice on our website; and • making copies of the revised Notice available upon request. We are required to follow the procedures in the Notice that is currently in effect.
HOW GOOD MEASURES MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU.
The following categories describe different ways that we may use and disclose Protected Health Information about you without your written authorization:
- For Treatment. We may use and disclose Protected Health Information about you to provide you with, coordinate, or manage your medical treatment or services. Specifically, we may share Protected Health Information about you with the physician, therapist, or other health professional or agency that referred you to us, as part of our effort to coordinate your follow-up care. We may also share Protected Health Information about you in order to coordinate different aspects of care that you need, such as prescriptions, lab work, or psychological services. We may disclose Protected Health Information about you to people who provide services in connection with your medical care.
- Payment for Services. We may use and disclose Protected Health Information about you so that the treatment and services you receive from us may be billed to you, an insurance company, or a third party. For example, we may need to give your health plan information about the nutrition services you received so your health plan will reimburse us or reimburse you for the service we provide. We may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the services.
- For Health Care Operations. We may use and disclose Protected Health Information about you for our health care operations, such as quality assessment and improvement activities, case management, business planning, customer services, and other activities. These uses and disclosures are necessary for our general operations, to reduce health care costs, and to make sure that all clients receive quality care. For example, we may use Protected Health Information during professional supervision to review our treatment and services and to evaluate our performance. We may also analyze Protected Health Information of our clients to decide what additional services we should offer, what services are not needed, and whether certain treatment approaches are effective.
- Subject to applicable federal and state law, in some limited situations the law allows or requires us to use or disclose your Protected Health Information without your written authorization for purposes other than treatment, payment, or health care operations. Please note that not all uses and disclosures described below will apply.
- As Required By Law. We will disclose Protected Health Information about you when required to do so by federal, state, or local law. We also will notify you of these uses and disclosures if Notice is required by law.
- Research. We may disclose your Protected Health Information to researchers without your authorization under limited circumstances, for example if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy.
- Health Risks. We may disclose Protected Health Information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.
- Judicial and Administrative Proceedings. If you are involved in a lawsuit or dispute, we may disclose your Protected Health Information in response to a court or administrative order. We may also disclose Protected Health Information 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, either by us or by the requesting party, to tell you about the request or to obtain an order protecting the information requested.
- Appointment Reminders, Treatment Alternatives, Benefits and Services. In the course of providing treatment to you, we may use your Protected Health Information to contact you with a reminder that you have an appointment for treatment or services. We may also use your Protected Health Information in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.
- Business Associates. We may disclose your Protected Health Information to business associates who perform services on our behalf (such as billing companies); however, if we disclose your Protected Health Information to a business associate, we will have a written contract with our business associate that ensures that our business associate also protects the privacy of your Protected Health Information.
- Public Health. As required by law, we may disclose your Protected Health Information to public health or legal officials (including a foreign government agency collaborating with such officials) charged with preventing or controlling disease, injury, or disability. We may also disclose your Protected Health Information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so. We may also release your Protected Health Information to government disease registries. And finally, we may release some Protected Health Information about you to your employer if your employer hires us to provide you with a physical exam and we discover that you have a work-related injury or disease that your employer must know about in order to comply with employment laws.
- To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health 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.
- Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- Law Enforcement. We may release Protected Health Information to law enforcement officials for certain reasons, such as in response to an order or warrant of a court, or to assist in the identification or location of an individual, victims of crime, or decedents, or if necessary to report a crime that occurred on our premises.
- Organ and Tissue Donation. If you are an organ donor, we may release Protected Health Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ, eye, or tissue donation and transplantation.
- Military and Veterans. If you are a member of the armed forces, we may release Protected Health Information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release Protected Health Information about foreign military personnel to the appropriate foreign military authority.
- National Security and Intelligence Activities or Protective Services. We may release your Protected Health Information to authorized federal officials for national security and intelligence purposes or for protective services to the President or other important officials.
- Coroners, Medical Examiners, and Funeral Directors. We may release Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose Protected Health Information to funeral directors consistent with applicable law to enable them to carry out their duties.
- Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Protected Health Information about you to the correctional institution or law enforcement official as necessary for your or another person's health and safety.
- Worker's Compensation. We may disclose your Protected Health Information as necessary to comply with laws relating to worker's compensation or other similar programs established by law.
- Food and Drug Administration. We may disclose to persons under the jurisdiction of the Food and Drug Administration, Protected Health Information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post- marketing surveillance information to enable product recalls, repairs, or replacement.
- Completely De-identified or Partially De-identified Information. We may use and disclose your Protected Health Information if we have removed any information that has the potential to identify you so that the Protected Health Information is “completely de- identified.” We may also use and disclose “partially de-identified” Protected Health Information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de- identified Protected Health Information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number).
- Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your Protected Health Information, certain disclosures of your Protected Health Information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your Protected Health Information.
DISCLOSURES TO WHICH YOU CAN OBJECT
Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose Protected Health Information about you without your authorization in the following circumstances:
- Family Members and Friends. We may share with a family member, relative, friend, or other person identified by you, Protected Health Information directly relevant to that person's involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition, or death.
- Disaster Relief. We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances.
If you would like to object to use and disclosure of Protected Health Information in these circumstances, please call (617) 531-9149 or email us at firstname.lastname@example.org.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding Protected Health Information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy Protected Health Information that may be used to make decisions about you, you must submit your request in writing to us. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we do, we will provide a written denial that explains our reasons for doing so, and a complete description of your rights to have that decision reviewed and how you can exercise those rights.
- Right to Amend. If you feel that Protected Health Information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to us. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or if it does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the Protected Health Information kept by us;
- Is not part of the information that you would be permitted to inspect and copy; or
- We believe is accurate and complete.
- If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records.
- Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of Protected Health Information about you. Many routine disclosures we make will not be included in this list; however, the accounting will include many non-routine disclosures. To request this list, you must submit your request in writing to us. You may ask for disclosures made up to six years before your request (not including disclosures made before April 14, 2003). The first list you request within a 12-month period will be free. For additional lists in that same 12- month period, we may charge you for the costs of providing the list.
- Right to Request Restrictions. You have the right to request restrictions on our use and disclosure of your Protected Health Information for treatment, payment, and health care operations. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction unless you request a restriction on our disclosure of Protected Health Information about you to a health plan for the purpose of carrying out payment or health care operations, and the Protected Health Information pertains solely to a health care item or service for which you or another person on your behalf has assumed full financial responsibility. If we do agree to your requested restriction, we will comply with your request unless the information is needed to provide you emergency treatment or the disclosure is to the Secretary of the Department of Health and Human Services. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. To request restrictions, you must make your request in writing to us.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to us. We will accommodate all reasonable requests.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time by contacting us.
- Right to be Notified Following a Breach of Unsecured Protected Health Information. If you are affected by a breach of your unsecured Protected Health Information, you have the right to, and will, receive notice of such breach.
OTHER USES AND DISCLOSURES
We will obtain your written authorization before using or disclosing your Protected Health Information for purposes other than those provided for above (or as otherwise permitted or required by law). Uses and disclosures of Protected Health Information that require your written authorization include: most uses and disclosures of psychotherapy notes, most uses and disclosures of Protected Health Information for marketing purposes, and disclosures that constitute a sale of Protected Health Information. If you provide us with written authorization, you may revoke that authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your Protected Health Information, except to the extent that we have already taken action in reliance on your authorization.
YOU MAY FILE A COMPLAINT ABOUT GOOD MEASURES PRIVACY PRACTICES
If you believe your privacy rights have been violated, you may file a complaint with us or file a written complaint with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact: Privacy Officer at 617-531-9149 or email@example.com. If you file a complaint, we will not take any action against you or change our treatment of you in any way.
© Good Measures, LLC 2017. Initial effective date: January 7, 2011. Current as of January 2, 2017.