HEALTH INFORMATION PRIVACY NOTICE

 

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access to This Information.

Please Review This Carefully.

 

About Protected Health Information (PHI). 

In this Notice, “we”, “our” or “us” means the Movement for Life clinics and our workforce of employees, contractors and volunteers. “You” and “your” refers to each of our patients who are entitled to a copy of this Notice.

 

We are required by federal and state law to protect the privacy of your health information. For example, federal health information privacy regulations require us to protect information about you in the manner that we describe here in this Notice. Certain types of health information may specifically identity you. Because we must protect this health information, we call this Protected Health Information---or “PHI”. In this Notice, we tell you about:

• How we use your PHI

• When we may disclose your PHI to others

• Your privacy rights and how to use them

• Our privacy duties

• Who to contact for more information or a complaint

 

Some of the ways we use (within the organization) or disclose (outside of the organization) your Protected Health Information

 

We will use your PHI to treat you. We will use your PHI and disclose it to get paid for your care and related services. We use or disclose your PHI for certain activities that we call “health care operations”. We will also use or disclose your PHI as required or permitted by law. We will give you examples of each of these to help explain them but space does not permit a complete list of all uses or disclosures. This is one reason why you can contact us and ask us questions.

1. TreatmentWe use and disclose your PHI in the course of your treatment. For instance, once we have completed your evaluation or re-evaluation we send a copy or summary of our report to your referring physician. We also maintain records detailing the care and services you receive at our facility so that we can be accurate and consistent in carrying out that care in an optimal manner; that record also assists us in meeting certain legal requirements. These records may be used and/or disclosed by members of our workforce to assure that proper and optimal care is rendered.

2. Payment Involving a Third Party PayerAfter we treat you we will, typically, bill a third party for services you received. We will collect the treatment information and enter the data into our computer and then process a claim either on paper or electronically. The claim form will detail your health problem, what treatments you received, and it will include other information such as your social security number, your insurance policy number, and other identifying pieces of information.  The third-party payer may also ask to see the records of your care to make certain that the services were medically necessary. When we use and disclose your information in this way is helps us to get paid for your care and treatment.

3. Payment Exclusive of a Third Party Payer (fully self-pay)If you choose to pay for your services, in full, without involving a third party (insurer, employer, etc.) you may request that we do not disclose any information regarding your services for payment purposes.

 

4. Health Care OperationWe also use and disclose your PHI in our health care operations. For example, our therapists meet periodically to study clinical records to monitor the quality of care at our facility. Your records and PHI could be used in these quality assessments. Sometimes we participate in student internship programs and we use the PHI of actual patients to test their skills and knowledge. Other operational uses may involve business planning and compliance monitoring or even the investigation and resolution of a complaint.

5. Special Uses  We also use or disclose your PHI for purposes that involve your relationship to us as a patient. We may use or disclose your PHI to:

• Update your workers' compensation case worker or employer

• Remind you of appointments

• Release equipment and/or supplies to your designee

• Carry out follow-ups on your home programs or discharge planning

• Advise you of new or updated services or home supplies via telecommunication or via a newsletter  (you can choose to opt-out of receiving information of this nature from us)

6. Uses & Disclosures Required or Permitted by LawMany laws and regulation apply to us that affect your PHI, they may either require or permit us to use or disclose your PHI. Here is a list from the federal health information privacy regulations describing required or permitted uses and disclosures:

Permitted:

• If you do not verbally object, we may share some of your PHI with a family member or a friend if he/she is involved in your care 

• We may use your PHI in an emergency if you are not able to express yourself

• If we receive certain assurance that protect your privacy, we may use or disclose your PHI for research; Movement for Life will always obtain authorization from you even though it is ‘permitted’ without one

Required:

• When required by law; for example, when ordered by a court to turn over certain types of your PHI, we must do so

• For public health activities such as reporting a communicable disease or reporting an adverse reaction to the Food and Drug Administration

• To report neglect, abuse or domestic violence

• To the government regulators or its agents to determine whether we comply with applicable rules and regulations

• In judicial or administrative proceedings such as a response to a valid subpoena

• When properly requested by law enforcement officials or other legal requirements such as reporting gunshot wounds 

• To avert a health hazard or to respond to a threat to public safety such as an imminent crime against another person 

• Deemed necessary by appropriate military command authorities if you are in the Armed Forces

• In connection with certain types of organ donor programs

• Stricter Requirements That We Follow.  Some of California’s regulations are more stringent than federal privacy regulations so we comply with those laws.

7. Your Authorization May Be RequireIn the situations noted above we have the right to use and disclose your PHI. In some situations, however, we must ask for, and you must agree to give, a written authorization that has specific instructions and limits on our use or disclosure of your PHI. If you change your mind, at a later date, you may revoke your authorization.

8. Your Privacy Rights and How to Exercise ThemYou have specific rights under our federally required privacy program. Each of them is summarized below:

• Your Right to Request Limited Use or Disclosure: You have the right to request that we do not use or disclose your PHI in a particular way. However, we are not required to abide by your request. If we do agree to your request we must abide by the agreement; we have the right to ask for that request to be in writing and we will exercise that right.

• Your Right to Confidential Communication: You have the right to receive confidential communications from us at a location or phone number that you specify. We have the right to ask for that request to be in writing noting the other address or phone number and confirmation that it should not interfere with your method of payment; we will exercise the right to have your request in writing.

• Your Right to Inspect and Copy Your PHI: You have the right to inspect and copy your PHI. If we maintain our records in paper, that will be the format utilized; however, if we maintain our records electronically you have the right to review and/or have copies made in an electronic format. Should we decline we must provide you with a resource person to assist you in the review of our refusal decision. We must respond to your request within fifteen (15) days, we may charge reasonable fees for copying and labor time related to copying and we may require an appointment for record inspection; we have the right to ask for your request in writing and will exercise that right. 

• Your Right to Revoke Your Authorization: If you have granted us authorization to use or disclose your PHI you may revoke it at any time in writing. Please understand that we relied on the authority of your authorization prior to the revocation and used or disclosed your PHI within its scope.

• Your Right to Amend Your PHI: You have a right to request an amendment of your record. We have the right to ask for the request in writing and we will exercise that right. We may deny that request if the record is accurate and/or if the record was not created by this facility. If we accept the amendment we must notify you and make effort to notify others who have the original record.

• Your Right to Know Who Else Sees your PHI (Records on paper): You have the right to request an accounting of certain disclosure that we have made over the past six years. We do not have to account for all disclosures, including those made directly to you, those involving treatment, payment, health care operations, those to the family/friend involved with your care and those involving national security. You have the right to request the accounting annually. We have the right to ask for the request in writing and to charge for any accounting requests that occur more than once per year; we must advise you of any charge and you have the right to withdraw your request or to pay to proceed. 

• Your Right to Know Who Else Sees your PHI (Records maintained electronically): You have the right to request an accounting of disclosures that we have made over the past three years. You have the right to request the accounting annually. We have the right to ask for the request in writing and to charge for any accounting requests that occur more than once per year; we must advise you of any charge and you have the right to withdraw your request or to pay to proceed.

• You Have a Right to Complain: You have the right to complain if you feel your privacy rights have been violated. You may complain directly to us by contacting our HIPAA officer noted in Section 10, or to the:

Office for Civil Rights, Region IX
U.S. Department of Health and Human Services
50 United Nations Plaza, Room 322
San Francisco, CA 94102
Voice Phone (415) 437-8310
Fax (415) 437-8329
TDD (415) 437-8311

 

We will not retaliate against you if you file a complaint about us. Your complaint should provide a reasonable amount of specific detail to enable us to investigate your concern.

9. Some of Our Privacy Obligations and How We Perform The

• We are required by law to maintain the privacy and security of your protected health information

• We will let you know promptly if a breach that may have compromised the privacy or security of your information

• We must follow the duties and privacy practices described in this notice and give you a copy of it

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind

If we change our Notice of Privacy Practices we will provide our revised Notice to you when you next seek treatment from us.

 

10. Contact InformationIf you have questions about this Notice, or if you have a complaint or concern, please contact:

Name: Kelly Sanders

Address: 1106 Walnut Street, #110

San Luis Obispo, CA 93401

Phone: 866-387-7778

 

Effective Date: This revised notice takes effect on September 23, 2013.