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.
This notice applies to PopHealthCare, including its affiliated medical professionals and employees. This notice will tell you how we may use and disclose medical information (also known as “protected health information”) about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Maintain the privacy and security of your medical information.
- Give you a copy of this notice describing our legal duties and privacy practices.
- Follow the duties and privacy practices of the notice that is currently in effect.
- Let you know in the event of a breach involving your unsecured medical information.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. We are also required to comply with any applicable state laws that impose stricter standards than those described in this notice. Your medical information may be stored electronically and is subject to electronic disclosure, including through a health information exchange.
- Treatment. We may use and disclose your medical information to provide you with medical treatment or services. For example, we may share information with your doctor or other professionals who are involved in taking care of you.
- Payment. We may use and disclose your medical information so that the services you have received from us may be billed to, and payment may be collected from, your health plan or other payor. For example, we may send your medical information to a health plan to request payment for services, contact payors to verify coverage or determine eligibility for benefits and disclose information to collection agencies.
- Health Care Operations. We may use and disclose your medical information to conduct our standard internal operations, including evaluating our quality, assessing our services, and arranging for legal services, when necessary. For example, we may use your information to evaluate our performance, use information you contact you to provide information about treatment alternatives or other healthrelated benefits and services that may be of interest to you.
- Individuals Involved in your Care or Payment for Your Care. Unless you object, we may disclose to your family members or others involved in your care information relevant to their involvement in your care or payment for your care or information necessary to inform them of your location and condition.
- As Required By Law. We will use and disclose medical information about you when required to do so by federal, state or local law, including disclosing information to the Department of Health and Human Services if it requests the information to determine how we are complying with federal privacy law.
- Public Health Activities. We may use disclose medical information about you for public health activities, including the collection of vital statistics, preventing disease and helping with product recalls.
- Abuse, Neglect or Domestic Violence. We may disclose medical information to appropriate agencies if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees, or if we are required or authorized to do so by law and we believe the disclosure is necessary to prevent serious harm.
- Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure.
- Lawsuits and Disputes. We may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process, but only if reasonable efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law Enforcement. We may disclose medical information to law enforcement for certain law enforcement purposes.
- National Security and Intelligence Activities. We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, presidential protective services and other national security activities authorized by law. If you are a member of the armed forces, we may disclose information as required by military command authorities.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.
- Deaths and Organ Donation. We may disclose information regarding deaths to coroners, medical examiners and funeral directors. We may use and disclose medical information to entities involved in procuring, banking and transplanting organs, eyes and tissues to assist with donation or transplantation.
- Serious Threat to Health and Safety. We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- Research. We may use and disclose information for certain research purposes, but only when we have approval from an IRB or other specific conditions are met.
- Workers Compensation. We may disclose information about you for workers compensation or similar programs providing benefits for work-related injuries or illness as required by state law.
- To Business Associates. We may disclose your medical information to third parties known as “Business Associates” that perform various activities (e.g. consulting services, legal services, delivery of goods) for us and that agree to protect the privacy of medical information.
- Limited Data Set. We may remove most information that identifies you from a set of data and use and disclose this data set for research, public health and health care operations, provided the recipients of the data set agree to keep it confidential.
OTHER USES AND DISCLOSURES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice will be made only with your written authorization. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your medical information for marketing purposes or sell your medical information unless you have signed an authorization. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the rights described below regarding medical information we maintain about you. If you have given another individual a medical power of attorney, if another individual is appointed as your legal guardian or if another individual is authorized by law to make health care decisions for you (known as a “personal representative”), that individual may exercise any of the following rights listed below. To exercise any of these rights, you must submit a written request to the PopHealthCare Privacy Officer at the address at the end of this notice (see contact information listed under “Contact Person” below).
- Right to Inspect and Copy. You have the right to inspect and request a copy of medical information that may be used to make decisions about your care or direct us to send a copy of your medical information to another person designated by you in writing. In most cases, we will provide this access to you or the person you designate within 30 days of your request. We may deny your request to inspect and copy in certain limited circumstances. If you request a copy of the information, we may charge a reasonable fee for our labor and supply costs for creating the copy and postage, if applicable. If your information is stored electronically and you request an electronic copy, we will provide it to you in a readable electronic form and format.
- Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. Your request must include a reason that supports your request. We may deny your request for limited reasons but will notify you of the reason for the denial in writing.
- Right to an Accounting of Disclosures. You have the right to request a list (accounting) of the disclosures we made of medical information about you. The list will not include disclosures that we are not required to record, such as disclosures you authorize. The first list you request within a 12-month period will be free, but we will charge a reasonable, cost-based fee if you ask for another one within 12 months. Your request may be for a time period not longer than six years.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. We are not required to agree to your request, except for requests to restrict disclosures to a health plan for
payment or health care operations, when you have paid in full out-of-pocket for your care and when the disclosures are not required by law. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about 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. You do not have to give a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
CHANGES TO THIS NOTICE
We are required to abide by the terms of our notices that is currently in effect. 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. If we change our notice, we will provide a copy of the revised notice to you upon request. A copy of the current notice is posted on our website, and we also have it on file at our offices.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer at the address at the end of this notice (see “Contact Person” below). All complaints must be submitted in writing. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not penalize you or retaliate against you for making a complaint.
Our Privacy Officer is our contact person for further information, to exercise any of the rights described above and for filing complaints with us. If you have questions, wish to exercise any of your privacy rights or would like to make a complaint, please call 1-855-574-1154, visit our website at www.pophealthcare.ethicspoint.com, send an email to firstname.lastname@example.org, or contact the Privacy Officer in writing at:
51 W. 3rd Street, Suite 500
Tempe, AZ 85281