NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS IT.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Effective Date: DEC 01, 2020.
This Notice of Privacy Practices (the “Notice”) is provided to you by AROSE eTHERAPY & LIFE DESIGN, LLC (“Company,” “We,” “Us,” and “Our”), as Company or its subsidiaries, affiliated entities, and business associates may be formed, incorporated, or operating in your state. This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that We provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.
PHI is information about your past, present, or future health or conditions or the tests and treatment you got from Us or other providers related to your physical and mental health. This information is stored in your health record. It can include: a) your history (e.g., things that happened to you as a child, your school and work experiences, your relationship and other personal history, medical history, psychological history, substance use history, and legal history); b) reasons you came for treatment (e.g., your complaints, symptoms, or needs); c) diagnoses; d) treatment plans; e) visit notes (which would include information about how you are doing, information shared, and observations of how you are doing; f) records from other providers; g) psychological test results, academic records or other reports; h) medications you took or are taking; i) legal matters; j) billing and insurance information; k) demographic information (e.g., name, address, phone, social security number, driver’s license number). There may also be additional information that is collected and stored.
We are committed to protecting your PHI. We will use it to the minimum extent necessary to accomplish the intended purpose of the use, disclosure, or request of it. This Notice provides you with information about your rights, and Our privacy practices with respect to your PHI. This Notice also discusses the uses and disclosures We will make of your PHI. We reserve the right to change the terms of this Notice from time-to-time and to make any revised notice effective for all PHI We then use, have access to, or control.
PERMITTED USES AND DISCLOSURES
We can use or disclose your PHI for purposes of treatment, payment, and healthcare operations. The following descriptions may not describe every particular use or disclosure in every category. The purposes of any given use may also vary pursuant to Company or its business affiliate/associate’s role.
· TREATMENT – the provision, coordination, or management of your healthcare, including consultations between healthcare providers.
· PAYMENT – the activities We undertake to obtain reimbursement for healthcare provided to you, including billing, collections, case management, and other utilization review activities.
· HEALTHCARE OPERATIONS – support functions for Our management services and providers, related to referral; facilitating the telehealth connection and visit; care coordination; compliance, training, or quality review programs We may institute; treatment; payment; receiving and responding to patient comments and complaints; audits; and other business planning, development, management, legal, and administrative activities.
OTHER USES AND DISCLOSURES OF PHI
We may also use your PHI in the following ways:
· To provide appointment reminders and schedule your treatment.
· To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.
· To your family, personal representative (“PR”), power of attorney, guardian, or any other individual identified by you to the extent directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a PR, or another person responsible for your care, of your general condition or death. If you are available, We will give you an opportunity to object to these disclosures, and We will not make these disclosures if you object. If you are not available, incapacitated, or unable to make informed consent decisions about your healthcare We will determine whether a disclosure to your family or PR is permitted or required by law, in your best interests, considering the circumstances, and act based upon Our professional judgment.
· When permitted by law, We may coordinate Our uses and disclosures of PHI with public or private entities authorized by law to assist in disaster relief efforts.
· In certain cases, We will provide your information to contractors, agents, and other parties who need the information in order to perform a service for Us (Our “Business Associates”), including, without limitation, to obtain payment for healthcare services, technology services providers, or carrying out other business operations. In those situations, PHI will be provided to those contractors, agents, and other parties as is needed to perform their contracted tasks. Business Associates will enter into an agreement requiring them to maintain the privacy of the PHI released to them.
· We may share your information with a law firm or risk management organization to maintain professional advice about how to manage risk and legal liability, including for potential or actual legal claims.
· When required to disclose PHI by applicable law.
· Incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.
· If a patient files a worker's compensation claim, and We are providing necessary treatment related to that claim, We must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.
SPECIAL SITUATIONS
Subject to the requirements of applicable law, We will make the following uses and disclosures of your PHI:
· Emergencies. In emergencies and as necessary to avoid serious harm or death.
· Organ and Tissue Donation. If you are an organ donor, to organizations handling organ procurement or transplantation and as necessary to facilitate tissue donation and transplantation.
· Military and Veterans. If you are a member of the Armed Forces, as required by military command authorities.
· Public Health Activities. We may disclose PHI about you for public health activities, including disclosures:
o to prevent or control disease, injury, or disability
o to report births and deaths
o to report suspected elder or child abuse or neglect in accord with applicable legal obligations
o to persons subject to the jurisdiction of the U.S. Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services, and to report reactions to medications or problems with products; or
o to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
· Health Oversight Activities. to federal or state agencies that oversee Our activities.
· Lawsuits and Disputes.
o If you are involved in a lawsuit or a dispute, or a guardianship proceeding, We may disclose PHI subject to certain limitations and only to the extent permissible by law.
o If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if We receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
o If a patient files a complaint or lawsuit against Us, We may disclose relevant information regarding that patient in order to defend ourselves.
· Law Enforcement. To a law enforcement request:
o In response to a court order, warrant, summons or similar process
o To identify or locate a suspect, fugitive, material witness, or missing person
o About the victim of a crime under certain limited circumstances
o About a death We believe may be the result of criminal conduct
o About criminal conduct on Our premises or during Our services; or
o In emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description, or location of the person suspected of committing the crime.
· Coroners, Medical Examiners, and Funeral Directors. To a coroner, medical examiner, or funeral director, as necessary for them to carry out their duties.
· National Security and Intelligence Activities. To authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law.
· Inmates. To a correctional institution about a patient in the custody of a law enforcement official as necessary to: (1) provide the patient with healthcare; (2) protect the patient’s health and safety or the health and safety of others; or (3) protect the safety and security of the correctional institution or law enforcement.
· Serious Threats. As permitted by applicable law and standards of ethical conduct, We may use and disclose PHI if we, in good faith, believe the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person.
· Abuse and Neglect and Threats to Safety. There are some situations in which We are legally obligated to take actions, which are necessary to attempt to protect others from harm, and in which some information may be revealed about a patient's treatment:
· If We know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires filing a report with the appropriate state through its Abuse Hotline. Once such a report is filed, additional information may need to be provided.
· If We know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires filing a report with the appropriate state through its Abuse Hotline. Once such a report is filed, additional information may need to be provided.
· If We believe there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, disclosure of information may be required to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
OTHER USES OF YOUR HEALTH INFORMATION
Certain uses and disclosures of PHI will be made only with your written authorization, including uses or disclosures:
· For marketing purposes; and
· The sale of PHI, as defined by applicable law.
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to Us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing and except to the extent We already have acted in reliance on your authorization.
YOUR RIGHTS
You have the right to request restrictions on Our uses and disclosures of PHI for treatment, payment, and healthcare operations. We will not agree to your request, however, unless the PHI pertains solely to your healthcare items or services for which you have paid the bill in full and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.
You have the right to receive a paper copy of this Notice and may ask Us to give you a copy of this Notice at any time. If you received this Notice electronically, We will still provide a paper copy to you upon request. You can request a paper copy from Our Privacy Officer, Dr. Rozycki, at 561-570-2112, or you can access a current version on Our website at
You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations, including electronically. To make such a request, you may submit your request in writing to the Privacy Officer (contact info below).
Exceptions. You have the right to inspect and copy your PHI contained in Our records, except for:
· Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding
· PHI involving tests or charting when your access is restricted by ethical or legal requirements; or
· If you are an inmate and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you.
Requests. To inspect or obtain a copy of your PHI, you may submit your request in writing to the Privacy Officer (contact info below). If you request a copy, We may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. We may also deny a request for access to PHI under certain circumstances such as if there is a potential for harm to yourself or others. If We deny a request for access for this purpose, you have the right to have Our denial reviewed in accordance with the requirements of applicable law.
You have the right to request an amendment to your PHI but We may deny your request for amendment if We determine that the PHI or record that is the subject of the request:
· Was not created by Us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment
· Is not part of your health or billing records or other records used to make decisions about you;
· Is not available for inspection as set forth above; or
· Is accurate and complete.
In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. To request an amendment to your PHI, you must submit your request in writing to the Privacy Officer (contact info below), along with a description of the reason for your request. A response will be given to you within 60 days of receiving your request.
Upon your request, we will provide you accounting of disclosures of PHI made by Us to individuals or entities other than to you for the six (6) years prior to your request, except for disclosures:
· To carry out treatment, payment, and healthcare operations as provided above
· Incidental to a use or disclosure otherwise permitted/required by applicable law
· Pursuant to your written authorization
· To persons involved in your healthcare or for other notification purposes as provided by law
· For national security or intelligence purposes as provided by law; or
· To correctional institutions or law enforcement officials as provided by law.
To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer. Your request must state a specific period for the accounting (e.g., the past year). We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
You have the right to receive a notification if there is a breach of your unsecured PHI.
Right to Treatment. You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Choose. You have the right to decide not to receive services with Us. If you wish, We will provide you with names of other qualified professionals.
Right to Terminate. You have the right to terminate therapeutic services with Us at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with Us in session before terminating or at least contact Us by phone letting Us know you are terminating services.
Right to Release Information with Written Consent. With your written consent, any part of your record can be released to any person or agency you designate. Together, We will discuss whether or not We think releasing the information in question to that person or agency might be harmful to you.
NOTICE REGARDING USE OF TECHNOLOGY
We may use electronic software, services, and equipment, including without limitation email, video conferencing technology, cloud storage and servers, internet communication, cellular network, voicemail, facsimile, electronic health record, and related technology to share PHI with you or third-parties subject to the rights and restrictions in this Notice. In any event, certain unencrypted storage, forwarding, communications and transfers may not be confidential. We will take measures to safeguard the data transmitted, as well as to ensure its integrity against intentional or unintentional breach or corruption. In rare circumstances, however, security protocols could fail, causing a breach of your privacy or PHI.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time and for any reason permissible by law. We reserve the right to make the revised Notice effective for PHI and health information We already have about you as well as any information We receive in the future. We will post a copy of the current Notice at www.arose-etherapy.com. The Notice will contain the effective date on the first page.
COMPLAINTS
If you believe that your privacy rights have been violated, you should immediately contact the Privacy Officer at DrRozycki@arose-etherapy.com. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services, where applicable.
CONTACT PERSON
If you have any questions or would like further information about this Notice, please contact the Privacy Officer at (561) 570-2112 or DrRozycki@arose-etherapy.com.