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.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Your health information may also be disclosed to other health care providers to assist them in obtaining payment for services they have provided to you.
Health care operations. Your health information may be used as necessary to review and adjust the day-to-day activities and management of PASITHEA. For example, information on the services you received may be used to support budgeting and financial reporting, fraud and abuse detection and compliance programs, and activities to evaluate and promote quality. We may also share your health information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share your medical information with our “business associates” that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your medical information.
Law Enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, to comply with government mandated reporting and for other law enforcement purposes.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
Required by Law. As required by law in certain circumstances other than public health reporting, your health information may be used and disclosed by our staff, but such use and disclosure will be limited to the relevant requirements of the law concerning such specific circumstances. For example, we may be required to disclose information in the course of an administrative or judicial proceeding. Further, in the case of a breach of unsecured protected health information, we will notify you as required by law.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you.
Other uses and disclosures require your authorization.
Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
You have certain rights under the federal privacy standards. These include:
• The right to request restrictions on the use and disclosure of your protected health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. We may not be required to agree to the restriction that you requested due to limitations contained in the applicable laws and we will notify you of our decision to reject your request;
• The right to receive communications from us concerning your medical condition and treatment through reasonable, confidential alternative means selected by you;
• The right to inspect and copy your protected health information. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary, as allowed by applicable law. We may deny your request under limited circumstances;
• The right to amend or submit corrections to your protected health information by submitting a written request including the reasons you believe the information is incorrect or incomplete. We are not required to change your health information and will provide you with information regarding our denial of such requested amendment. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal;
• The right to receive an accounting of how and to whom your protected health information has been disclosed; provided, however, we are not required to provide to you an
accounting of disclosures made for the purposes of treatment, payment, health care operations, information provided directly to you, information provided pursuant to your written authorization, and certain government functions; and
• The right to receive a printed copy of this notice.
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. We will also prominently post the current notice on our website. The revised policies and practices will be applied to all protected health information that we maintain, regardless of when it was created or received.
Requests to Inspect
Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Compliance Officer at the telephone number and address set forth below.
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns. You also have the right to submit a complaint to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated.
If you believe that your privacy rights have been violated, you should call the matter to our attention by contacting the Compliance Officer at the telephone number set forth below, or by sending a letter describing the cause of your concern to the address set forth below.
You will not be penalized or otherwise retaliated against for filing a complaint.
For further information concerning our privacy practices please contact:
The Compliance Officer, +1 (888) 664-7284, firstname.lastname@example.org
53 West 36th St, Suite 204, New York, New York 10018
This notice is effective on May 21, 2021.