49 Hartford Turnpike    |    Vernon, CT    |    860.288.4104

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Thursday, April 20, 2017

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NOTICE OF PRIVACY PRACTICE HEALTHWISE MEDICAL ASSOCIATES, LLP

EFFECTIVE AS OF 9/23/2013

We Care About Your Privacy:

Protec'ng your confiden'al health informa'on is important to us. This no'ce describes how medical informa'on about you may be used and disclosed and how you can get access to this informa'on. Please review carefully.

Healthwise Promise:

The privacy of your health informa'on is important to us. We understand that your health informa'on is personal and we are commi=ed to protec'ng it. This no'ce describes how we may use and disclose your protected health informa'on to carry out treatment, payment or health care opera'ons and for other purposes that are permi=ed or required by law. It also describes your rights to access and control your protected health informa'on. “Protected Health Informa'on” is informa'on about you, including demographic informa'on, that may iden'fy you and that relates to your past, present and future physical or mental health or condi'on and related health care services.

Our Legal Duty:

We are required by law to maintain the privacy of your protected health informa'on; give you this no'ce of our legal du'es and privacy prac'ces with respect to your protected health informa'on; and follow the terms of our no'ce that are currently in effect. We may change the terms of our no'ce at any 'me. The new no'ce will be effec've for all protected health informa'on that we maintain at the 'me as well as any informa'on we receive in the future.

You can obtain any revised HIPAA No'ce of Privacy Prac'ces by contac'ng your provider’s office.

How Healthwise May Use and Disclose Your Protected Health InformaQon:

The following examples describes different ways that we may use and disclose your protected health informa'on. These examples are not meant to be exhaus've, but to describe the types of uses and disclosures that may be made by our office. We are permi=ed to use and disclose your protected health informa'on for the following purposes. However, our office may never have a reason to make some of these disclosures.

For Treatment:

We will use and disclose your protected health informa'on to provide, coordinate, or manage your health care treatment and any related services. We may also disclose protected .health informa'on to other physicians who may be trea'ng you. For example, your protected informa'on may be provided to a physician to whom you have been referred to ensure that the physician has the necessary informa'on to diagnose or treat you.

In addi'on, we may disclose your protected health informa'on from 'me-to-'me to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your healthcare diagnosis or treatment.

For Payment:

Your protected health informa'on will be used, as needed, to obtain payment for your health care service. This may include certain ac'vi'es that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determina'on of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking u'liza'on review ac'vi'es. For example, obtaining approval for a hospital stay may require that your relevant protected health informa'on be disclosed to your health plan to obtain approval for hospital admission.

For Health Care OperaQons:

We may use and disclose your protected health informa'on for health care opera'on purposes. These uses and disclosures are necessary to make sure that all of our pa'ents receive quality care and for our opera'on and management purposes. For example, we may use your protected health informa'on to review the treatment and services you receive to check on the performance of our staff in caring for you. We also may disclose informa'on to doctors, nurses, technicians, medical students, and other personnel for educa'on and learning purposes. The en''es and individuals covered by this no'ce also may share informa'on with each other for purposes of our joint health care opera'ons.

Appointment Reminders/Treatment AlternaQves/Health-Related Benefits and Services:

We may use and disclose your protected health informa'on to contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment op'ons or alterna'ves or health related benefits and services that may be of interest to you.

Fundraising AcQviQes:

We may use and disclose your demographic informa'on and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising ac'vi'es supported by our office. If you do not want to receive these materials, please contact your provider’s office and request that these fundraising materials not be sent to you.

Plan Sponsors:

If your coverage is through an employer sponsored group health plan, we may share protected health informa'on with your plan sponsor.

Facility Directories:

Unless you object, we may use and disclose in our facility directory, your name, the loca'on at which you are receiving care, your condi'on (in general terms), and your religious affilia'on. All of this informa'on, except religious affilia'on, will be disclosed to people that ask for you by name. Members of the clergy will be told your religious affilia'on. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health informa'on. If you are not present or able to agree or object to the use or disclosure of the protected health informa'on, then your provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health informa'on that is relevant to your to your health care will be disclosed.

Others Involved in Your Health Care:

Unless you object, we may disclose to a member of your family, a rela've, a close friend or any other person you iden'fy, your protected health informa'on that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such informa'on as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health informa'on to no'fy or assist in no'fying a family member, personal representa've or any other person that is responsible for your care of your loca'on, general condi'on or death. Finally we may use or disclose your protected health informa'on to an authorized public or private en'ty to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Required by Law:

We may use or disclose your protected health informa'on to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be no'fied, as required by law, of any such uses or disclosures.

Public Health:

We may disclose your protected health informa'on for public health ac'vi'es and purposes to a public health authority that is permi=ed by law to collect or receive the informa'on. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health informa'on, if directed by the public health authority, to a foreign government agency that is collabora'ng with the public health authority.

Business Associates:

We may disclose your protected health informa'on to our business associates that perform func'ons on our behalf or provide us with services if the informa'on is necessary for such func'ons or services. For example, we may use another company to perform func'ons on our behalf or provide us with services if the informa'on is necessary for such func'ons or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your informa'on and are not allowed to use or disclose any informa'on other than as specified in our contract.

Communicable Diseases:

We may disclose your protected health informa'on, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contrac'ng or spreading the disease or condi'on.

Health Oversight:

We may disclose your protected health informa'on to a health oversight agency for ac'vi'es authorized by law, such as audits, inves'ga'ons, and inspec'ons. Oversight agencies seeking this informa'on include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Food and Drug AdministraQon:

We may disclose your protected health to a person or company required by the Food and Drug Administra'on to report adverse events, product defects or problems, biologic product devia'ons, track products to enable product recalls, to make repairs or replacements, or to conduct post marke'ng surveillance, as required by law.

Coroners, Funeral Directors, and Organ DonaQon:

We may disclose your protected health informa'on to a coroner or medical examiner for iden'fica'on purposes, determining cause of death or for the coroner or medical examiner to perform other du'es authorized by law. We may also disclose your protected health informa'on to a funeral director, as authorized by law, in order to permit the funeral director to carry out their du'es. We may disclose such informa'on in reasonable an'cipa'on of death. Protected health informa'on may be used and disclosed for cadaveric organ, eye or 'ssue dona'on purposes.

Research:

We may disclose your protected health informa'on to researchers when their research has been approved by an ins'tu'onal review board that has reviewed the research proposal and established protocol to ensure the privacy of your protected health informa'on.

Criminal AcQvity:

Consistent with applicable federal and state laws, we may disclose your protected health informa'on, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may so disclose your protected health informa'on if it is necessary for law enforcement authori'es to iden'fy or apprehend an individual.

Military AcQvity and NaQonal Security:

When the appropriate condi'ons apply, we may use or disclose protected health informa'on of individuals who are Armed Forces personnel (1) for ac'vi'es deemed necessary by appropriate military command authori'es; (2) for the purpose of a determina'on by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health informa'on to authorized federal officials for conduc'ng na'onal security and intelligence ac'vi'es, including for the provision or protec've services to the President or others legally authorized.

Workers’ CompensaQon:

Your protected health informa'on may be disclosed by us as authorized to comply with workers’ compensa'on laws and other similar legally established programs.

Inmates:

We may use or disclose your protected health informa'on if you are an inmate of a correc'onal facility and your provider created or received your protected health informa'on in the course of providing care to you.

For Data Breach NoQficaQon Purposes:

We may use or disclose your protected health informa'on to provide legally required no'ces of unauthorized acquisi'on, access, or disclosure of your health informa'on. We may send no'ce directly to you or provide no'ce to the sponsor of your plan, if applicable, through which you receive coverage.

Required Uses and Disclosures:

Under the law, we must make disclosures to you and when required by the Secretary of the U.S. Department of Health and Human Services to inves'gate or determine our compliance with requirements of Sec'on 164.500 et. seq.

Special ProtecQons for HIV, Alcohol and Substance Abuse, Mental Health and GeneQc InformaQon:

Certain Federal and state laws may require special privacy protec'ons that restrict the use and disclosure of certain health informa'on, including HIV-related informa'on, alcohol and substance abuse informa'on, mental health informa'on and gene'c informa'on. For example, a health plan is not permi=ed to use or disclose gene'c informa'on for underwri'ng purposes. Some parts of this HIPAA No'ce of Privacy Prac'ces may not apply to these types of informa'on. If your treatment involves this informa'on, you may contact your provider’s office for more informa'on about these protec'ons.

Uses and Disclosures of Protected Health InformaQon Based Upon Your WriZen AuthorizaQon:

Uses and disclosures of your protected health informa'on that involve the release of psychotherapy notes (if any), marke'ng, sale of your protected health informa'on, or other uses or disclosures not described in this no'ce will be made only with your wri=en authoriza'on, unless otherwise permi=ed or required by law. You may revoke this authoriza'on at any 'me, in wri'ng, except to the extent that this office has taken an ac'on in reliance on the use or disclosure indicated in the authoriza'on. Addi'onally, if a use or disclosure of protected health informa'on described above in this no'ce is prohibited or materially limited by other laws that apply to use, it is our intent to meet the requirements of the more stringent law.

Your Rights Regarding Health InformaQon About You:

The following are statements of your rights with respect to your protected health informa'on and a brief descrip'on of how you may exercise these rights:

1) You have the right to inspect and copy your protected health informa'on. This means you may inspect

and obtain a copy of your protected health informa'on that is contained in your designated file for as long as we maintain the protected health informa'on. A “designated file” contains medical and billing records and any other records that your physician and the office uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, informa'on compiled in reasonable an'cipa'on of, or use in, a civil, criminal, or administra've ac'on or proceeding, and protected health informa'on that is subject to law that prohibits access to protected health informa'on. You must make a wri=en request to inspect and copy our designated file. We may charge a reasonable fee for any copies.

Additonally, if we maintain an electronic health record of your designated file, you have the right to request that we send a copy of your protected health informa'on in an electronic format to you or to a third party that you iden'fy. We may charge a reasonable fee for sending the electronic copy of your protected health informa'on.

Depending on the circumstances, we may deny your request to inspect and/or copy your protected health informa'on. A decision to deny access may be reviewable. Please contact your provider’s office if you have any ques'ons about access to your medical record.

  1. 2)  You have the right to request a restric'on of your protected health informa'on. This means you may

    ask us not to use or disclose any part of your protected health informa'on for the purpose of treatment, payment or healthcare opera'ons. You may also request that any part of your protected health informa'on not be disclosed to family members or friends who may be involved in your care or for no'fica'on purposes as described in this HIPAA No'ce of Privacy Prac'ces. Your request must state the specific restric'on requested and to whom you want the restric'on to apply. Healthwise is not required to agree to a restric'on unless you are asking us to restrict the use and disclosure of your protected health informa'on to a health plan for payment or health care opera'on purposes and such informa'on you wish to restrict pertains solely to a health care item or service for which you paid us out-of-pocket in full. If HealthWise believes it is in your best interest to permit the use and disclosure of your protected health informa'on, your protected health informa'on will not be restricted. If Healthwise does agree to the requested restric'on, we may not use or disclose your protected health informa'on in viola'on of that restric'on unless it is needed to provide emergency treatment. With this in mind, please discuss any restric'on you wish to request with your provider. You may request a restric'on by contac'ng your provider’s office.

  2. 3)  You have the right to restrict informa'on given to your third-part payer if you fully pay for the services out of your pocket. If you pay in full for services out of your own pocket, you can request that the informa'on regarding the services not be disclosed to your third-party payer because no claim is being made against the third-party payer.

  3. 4)  You have the right to request to receive confiden'al communica'ons from us by alterna've means or at an alterna've loca'on. We will accommodate reasonable requests. We may also condi'on this accommoda'on by asking you for informa'on as to how payment will be handled or specifica'on of an alterna've address or other method of contact. We will not request an explana'on from you as to the basis for the request. Please make this request in wri'ng at your provider’s office.

  4. 5)  You have the right to have your physician amend your protected health informa'on. This means you may request an amendment of protected health informa'on about you in your designated file for as long as we maintain this informa'on. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement and we will provide you with a copy of any such rebu=al. Please contact your provider’s office if you have ques'ons about amending your medical record. Your request must be in wri'ng and provide the reasons for the requested amendment.

  5. 6)  You have the right to receive an accoun'ng of certain disclosures we have made, if any, of your protected health informa'on. This right applies to disclosures for purposes other than treatment, payment or health care opera'ons as described in the HIPAA No'ce of Privacy Prac'ces. It excludes disclosures we may have made to you, for the facility directory, to family members or friends involved in your care, or for no'fica'on purposes. The right to receive this informa'on is subject to certain excep'ons, restric'ons and limita'ons. Addi'onally, limita'ons are different for electronic health records.

  1. 7)  You have the right to obtain a paper copy of this no'ce from us, upon request, even if you have agreed

    to accept this no'ce electronically.

  2. 8)  You have the right to receive no'ce of a security breach: We are required to no'fy you if your protected health informa'on has been breached. The no'fica'on will occur by first-class mail within 60 days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security or your protected health informa'on. The no'ce will contain the following informa'on: (1) a brief descrip'on of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from poten'al harm resul'ng from the breach; and (3) a brief descrip'on of what we are doing to inves'gate the breach, mi'gate losses, and to protect against further breaches.

COMPLAINTS:
IF YOU HAVE ANY QUESTIONS OR COMPLAINTS ABOUT THIS NOTICE, PLEASE NOTIFY THE HEALTHWISE PRIVACY OFFICER: HEALTHWISE COMPLIANCE OFFICER, Renee Irvin, 49 HARTFORD TURNPIKE, VERNON, CT 06066

If you think Healthwise may have violated your privacy rights, please contact our privacy officer, either by mail or via our website: Healthwisema.com

You may also file a complaint with the U.S. Department of Health and Human Services.

The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Avenue S.W.
Washington, D.C. 20201

HealthWise will not retaliate against your for filing a complaint.

EFFECTIVE: 9/23/2013


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