Notice of Privacy Practices

Notice of Privacy Practices for Protected Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

Clineva is permitted by federal privacy laws to make use and disclosure of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of Uses of Your Health Information for Treatment Purposes are:

• A nurse obtains treatment information about you and records it in a health record.
• During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.
• We may contact you to provide reservation reminders.

Example of Use of Your Health Information for Payment Purposes:

We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of Use of Your Information for Health Care Operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol, and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Choices

For certain health information, you can tell us your choices about what we share. Tell us what you want us to do, and we will follow your instructions as required by law.

You may tell us whether to:

• Share information with your family, close friends, or others involved in your care or payment for your care; and
• Share information in a disaster relief situation.

If you are unable to tell us your preference, such as when you are unconscious, we may share your information if we believe it is in your best interest. We may also share information when needed to lessen a serious and imminent threat to health or safety.

We will not use or share your information for marketing purposes, for the sale of your information, or for most sharing of psychotherapy notes unless you give us written permission.

Use and Disclosure of PHI Without Your Authorization

Clineva is permitted to use PHI without your written authorization, or opportunity to object in certain situations, including:

Communication with Family

To a family member, other relative, or close personal friend, or other individual involved in your care if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure, and you do not raise an objection. We may also disclose health information to your family, relatives, or friends if we infer from the circumstances that you would not object.

For example, we may assume you agree to our disclosure of your personal health information to your spouse when your spouse has called the ambulance for you. In situations where you are not capable of objecting (because you are not present or due to your incapacity or medical emergency), we may, in our professional judgment, determine that a disclosure to your family member, relative, or friend is in your best interest. In that situation, we will disclose only health information relevant to that person's involvement in your care.

Notification

Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Research

We may use or share your information for health research as permitted by law.

Organ and Tissue Donation

We may share health information about you with organ procurement organizations as permitted by law.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Employers

We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employers.

Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat

To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions

We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Coroners, Medical Examiners, and Funeral Directors

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties.

Other Uses

Any other use or disclosure of PHI, other than those listed above will only be made with your written authorization, (the authorization must specifically identify the information we seek to use or disclose, as well as when and how we seek to use or disclose it).

You may revoke your authorization at any time, in writing, except to the extent that we have already used or disclosed medical information in reliance on that authorization as previously provided in this Notice under "Your Health Information Rights."

Substance Use Disorder Patient Records

To the extent that Clineva has your substance use disorder patient records that are subject to 42 CFR part 2, Clineva will not use or share those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Your Health Information Rights

The health and billing records we maintain are the physical property of Clineva. The information in it, however, belongs to you. You have a right to:

• 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. We will provide a copy or 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 believe is incorrect or incomplete. We may deny your request, but we will explain why in writing within 60 days. We may deny a request to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the health information kept by or for the Practice;
  • Is not part of the information that you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Request confidential communications. You can ask us to contact you in a specific way or to send mail to a different address. We will accommodate 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 generally are not required to agree, and we may deny the request 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 with your health insurer for payment or health care operations. We will agree unless a law requires us to share the information.
• Get a list of those with whom we have shared information. You can ask for an accounting of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. The accounting will not include disclosures for treatment, payment, or health care operations and certain other disclosures allowed by law. We will provide one accounting in a 12-month period for free and may charge a reasonable, cost-based fee for another request within the same 12 months.
• Get a copy of this privacy notice. You can ask for a paper copy at any time, even if you agreed to receive it electronically. We will provide a paper copy promptly.
• Choose someone to act for you. If someone has authority to act as your personal representative, such as through a medical power of attorney or legal guardianship, that person can exercise your rights and make choices about your health information. We will verify that authority before taking action.
• Appeal a denial of access to your protected health information, except in certain circumstances.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;

• Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our clinic, except to the extent information or action has already been taken.

Our Responsibilities

Clineva is required to:

• Maintain the privacy and security of your protected health information as required by law;
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your information;
• Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
• Follow the duties and privacy practices described in this Notice and provide you with a copy;
• Notify you if we cannot accommodate a requested restriction or request; and,
• Accommodate your reasonable requests regarding methods to communicate health information with you.

We will not use or share your information other than as described in this Notice unless you tell us we can in writing. You may change your mind at any time by notifying us in writing, except to the extent that we have already acted in reliance on your authorization.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, report a problem regarding the handling of your information, or if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to:

You may also 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 the HHS HIPAA complaint page.

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the clinic.

We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.