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.
Health care related information about you is private and is protected by state and federal laws. Hopebridge LLC (“Hopebridge) works hard to respect your privacy and will safeguard your information in accordance with applicable laws and regulations. This Notice of Privacy Practices (“Notice”) describes the privacy practices of Hopebridge with respect to your protected health information (“PHI”). This Notice is available to you on our company website at www.hopebridge.com (“Website”) and, upon request, at all clinic locations.
I. Our Duty to Safeguard Your Protected Health Information
Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for your health care is considered PHI. We understand that information about you is personal and we are committed to protecting information about you. We are required by law to:
- Maintain the privacy of your PHI
- Give you this notice of our legal duties and privacy practices regarding your PHI
- Notify affected individuals following a breach of unsecured PHI
- Follow the terms of our Notice currently in effect
This Notice explains how, when and why we may use or disclose your PHI. In general, we must access, use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure. If we discover a breach of your PHI, we are required to notify you of the breach.
We must follow the privacy practices described in this Notice, though we reserve the right to change the terms of this Notice at any time. We reserve the right to make new Notice provisions effective for all PHI we currently maintain or that we receive in the future. If we change this Notice, we will post a new Notice in our patient forms, clinics and Website. You may request a copy of the Notice from the clinic or obtain the Notice on our Website.
II. How We May Use and Disclose Your Protected Health Information
We access, use and disclose PHI for a variety of reasons. The following section offers more descriptions and examples of our potential access, uses, and disclosures of your PHI. Other uses and disclosures not described in this Notice will be made only with your authorization.
Uses and disclosures relating to treatment, payment, or health care operations. Generally, we may access, use, and disclose your PHI:
- For treatment. We may use and disclose your PHI with individuals involved in providing or coordinating your health care. For example, we may disclose PHI to medical doctors, therapists, or other personnel, including people outside of our office, including referring providers, who are involved in your medical care and need the information to provide you with medical care. We may also make your PHI available electronically through one or more health information exchanges or organizations (“HIOs”) to other health care providers, health plans or health care clearinghouses. Our participation in HIOs helps us care for you.
- To obtain payment. We may use and disclose your PHI so that we or others may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may release portions of your health plan information to Medicare/Medicaid, a private insurer or group health plan to get paid for services that we delivered to you. We may release your PHI to the state Medicaid agency to determine your eligibility for publicly funded services.
- For health care operations. We may use and disclose your PHI for health care operations purposes. These uses, and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage our organization. For example, we may use and disclose information to make sure the counseling you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Sharing your PHI through HIOs, as noted above, may also occur as part of our health care operations. Further, we may use and disclose your PHI to our auditors or attorneys for audit or legal purposes. We may also share PHI with health care provider licensing bodies like the State’s Department of Health or Child Protective Services.
- For appointment reminders, treatment alternatives, and health related benefits and services. We may use and disclose PHI to contact and remind you of an appointment with your provider. We also may use and disclose PHI to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
Uses and disclosures requiring authorization. For other uses and disclosures not described in this Notice, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. You may revoke an authorization by notifying us in writing. If you revoke your authorization, we will stop the uses and disclosures of your PHI for the purposes or reasons covered by your written authorization as of the date we receive your revocation. Your revocation will not apply to information already released. (See Section VI for instructions on revoking an authorization.) We cannot refuse to treat you if you do not sign an authorization to release PHI, unless services provided are solely to create health records for a third party, like physical exam for an insurance company; or if treatment provided is research-related and authorization is required for the use of PHI for research purposes. We will not sell your PHI or use and disclose your PHI for marketing purposes without your authorization. We will not disclose any psychotherapy notes (as defined by the Health Insurance Portability & Accountability Act) without your authorization.
Uses and disclosures not requiring authorization. The law allows us to access, use, and disclose your PHI without your authorization in certain situations, including but not limited to:
- When required by law. We will disclose PHI when required to do so by federal, state or local law. For example, we may disclose PHI in relation to cases of abuse, neglect, domestic violence, and certain physical injuries. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
- To avert a serious threat to health or safety. We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
- For public health activities and risks. We may disclose PHI for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; and 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. We will only make this disclosure if you agree or when required or authorized by law.
- Health oversight activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- For research purposes. In certain circumstances, we may disclose PHI to assist medical research, such as comparing the health and recovery of all patients who received one treatment to those who received another. We will ask for your permission if the researcher will have access to your PHI or will be involved in your care.
- Relating to decedents. We may disclose PHI relating to an individual’s death to coroners, medical examiners, funeral directors, and organ procurement organizations.
- Data breach notification purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your PHI.
- Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law enforcement. We may release PHI if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime on our premises.
- Business associates. We may disclose PHI to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform informational services on our behalf. All our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract with the business associate.
- Workers’ compensation. We may release PHI for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness
- An inmate of a correctional institution does not have the rights listed in this Notice.
Uses and Disclosures Requiring You to Have an Opportunity to Object: In the following situations, we may disclose your PHI if we tell you about the disclosure in advance and you have the opportunity to agree to, prohibit, or restrict the disclosure, and you do not object to such disclosure. However, if there is an emergency and you cannot be given the opportunity to agree or object, we may disclose your PHI if it is consistent with any prior expressed wishes and the disclosure is determined to be in your best interests.
- To families, friends or others involved in your care. We may share with your family, your friends or others involved in your care information directly related to their involvement in your care or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or your death.
- Disaster relief: In the event of a disaster, we may release your PHI to a public or private relief agency, for purposes of notifying your family and friends of your location, condition or death.
III. Your Rights Regarding Your Protected Health Information
You have the following rights regarding PHI:
- Right to inspect and copy your PHI. You have a right to inspect and obtain a copy of your PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes or information gathered for judicial proceedings. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee, as permitted by law, for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
- Right to request restrictions on your PHI. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a diagnosis or treatment with a spouse. We are not required to agree to your request except in limited circumstances involving certain disclosures to a health plan. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
- Right to request confidential communication. You have the right to request that we communicate with you about medical matters and information in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
- Right to amend your PHI. If you feel that PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by Hopebridge. We are not, however, required to honor your request if it is not in writing or does not include a reason to support the request. In addition, we may deny your request in certain circumstances.
- Right to an accounting of disclosures. You have the right to request a list of certain disclosures we made of your PHI. We are not required to provide an accounting of disclosures that were made for treatment, payment and health care operations, to you directly, in instances for which you provided written authorization, and in other limited circumstances. Your request for an accounting of disclosures must state a period that may not be longer than six (6) years from the date of your request. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a twelve (12) month period will be free. For additional lists, we may charge you for the cost of providing the list. 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.
- Right to an electronic copy of electronic medical records. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee, as permitted by law, for the labor associated with transmitting the electronic medical record.
Right to a paper copy of this Notice: You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our Website. Paper copies of this notice are available at any of our clinics.
IV. How to Complain About Our Privacy Practices
If you think we may have violated your privacy rights or if you disagree with a decision we made about access to your PHI, you may file a complaint with a person listed in Section V below. You may also submit an anonymous complaint by calling (844)-387-1352. You may also file a complaint with the U.S. Department of Health and Human Services and Office of Civil Rights. You will not be penalized if you file a complaint.
V. Contact Persons for Information or to Submit a Complaint
If you have questions about this Notice or complaints about our privacy practices, please contact:
Kevin Burton, Director, Patient Intake
Matt Ely, Director, Compliance and Risk Management
Hopebridge is committed to an ethical and compliant workplace. To report a complaint or violation, contact the Compliance hotline at: (844)-387-1352, or email at email@example.com. Your report will be confidential unless disclosure is required by law, and anonymous if so desired. You will not be penalized if you file a complaint.
VI. Instructions for Revoking an Authorization
You may revoke an authorization to access, use or disclose your PHI, in writing, except: 1) to the extent that action has been taken in reliance on the authorization or 2) if the authorization was obtained as a condition of obtaining insurance coverage and the insurer is questioning a claim under the policy. Your written revocation must include the date of the authorization, the name of the person or organization authorized to receive the PHI, your signature and the date you signed the revocation. Written revocation must be addressed to: Patient Intake Department, Release of Information, 3500 DePauw Boulevard, Suite 3070, Indianapolis, IN 46268. Such revocation will not be effective until received by Hopebridge.
VII. CHANGES TO THIS NOTICE
We reserve the right to change this Notice and make the new Notice apply to PHI we already have as well as any information we receive in the future. We will post a copy of our current Notice at our clinics and Website. The Notice will contain the effective date on the last page with the updated dates as stated in Section VIII.
VIII. Effective Date
This Notice was effective on 4/14/03. This Notice was updated on 12/31/17.