This notice describes how health/medical information about you may be used and disclosed and how you can get access to this information (aka: HIPAA). Please review it carefully. Effective date: July 1, 2016.
WHEN IT COMES TO YOUR HEALTH INFORMATION, YOU HAVE CERTAIN RIGHTS. THIS SECTION EXPLAINS YOUR RIGHTS AND SOME OF OUR RESPONSIBILITIES TO HELP YOU:
GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
ASK US TO CORRECT YOUR MEDICAL RECORD
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
REQUEST CONFIDENTIAL COMMUNICATIONS
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
ASK US TO LIMIT WHAT WE USE OR SHARE
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
GET A LIST OF THOSE WITH WHOM WE’VE SHARED INFORMATION
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We may charge a reasonable, cost-based fee for this.
GET A COPY OF THIS PRIVACY NOTICE
This notice is available on our website (www.holisticlactation.com). You can also request that a PDF version of the notice be emailed to you.
CHOOSE SOMEONE TO ACT FOR YOU
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE VIOLATED
• You can complain if you feel we have violated your rights by contacting us using the information on the final page of this document.
• We will not retaliate against you for filing a complaint.
YOU HAVE SOME CHOICES IN THE WAY THAT WE USE AND SHARE INFORMATION AS WE:
• Tell family and friends about your condition
For certain health information, you can tell us your choices about what we share. You have the right and choice to tell us to share information with your family, close friends, or others involved in your care. If you have a clear preference for how we share your information, talk to us. Tell us what you want us to do, and we will follow your instructions.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
HOW DO WE TYPICALLY USE OR SHARE YOUR HEALTH INFORMATION? WE TYPICALLY USE OR SHARE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:
We can use your health information and share it with other professionals who are treating you.
RUN OUR ORGANIZATION
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
BILL FOR YOUR SERVICES
We can use and share your health information to create documents that you can submit to your insurance company for reimbursement. We can use and share your health information to bill and get payment from health plans or other entities when applicable.
HOW ELSE CAN WE USE OR SHARE YOUR HEALTH INFORMATION?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research.
HELP WITH PUBLIC HEALTH AND SAFETY ISSUES
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
COMPLY WITH THE LAW
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
ADDRESS LAW ENFORCEMENT AND OTHER GOVERNMENT REQUESTS
WE CAN USE OR SHARE HEALTH INFORMATION ABOUT YOU:
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
RESPOND TO LAWSUITS AND LEGAL ACTIONS
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
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 occurs 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.
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice at any time, and the changes will apply to all information we have about you. The new notice will be available upon request and on our web site.
If you have questions about this notice, or would like to discuss this Notice of Privacy Practices, please contact the Privacy Officer listed below. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer listed below or with the Secretary of the US Department of Health and Human Services.
Holistic Lactation LLC
Privacy Officer: Jacqueline Kincer
4500 N. 32nd St., Suite 201D, Phoenix, AZ 85018
US Department of Health and Human Services
Office of the Secretary
200 Independence Avenue SW
Washington, DC 20201
Phone: 202.619.0257 or 1.877.696.6775