HIPAA NOTICE OF PRIVACY PRACTICES

Please read and sign at the bottom. 

 

Effective Date: June 1, 2018

 

This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing.

 

Questions about this notice can be directed to Brittany Summerlin, Powered by Plants, LLC; phone: (678) 575-5089 email: info@eatwellatl.com

 

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION:

We, Powered by Plants, LLC, understand that protected health information about you and your health is personal. We are committed to protecting your health information. This Notice applies to all the records of your care generated by Powered by Plants, LLC. This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information.

The law requires us to:

  • make sure that protected health information that identifies you is kept private

  • notify you about how we protect protected health information about you

  • explain how, when and why we use and disclose protected health information

  • follow the terms of the Notice that is currently in effect.

 

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by:

  • posting the revised Notice in our office

  • making copies of the revised Notice available upon request

  • posting the revised Notice on our website.

 

 

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose protected health information without your written authorization.

 

For Treatment: We may use protected health information about you to provide you with, coordinate or manage your medical treatment or services within the practice. We may disclose protected health information about you to Powered by Plants, LLC personnel who are involved in taking care of you. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care Powered by Plants, LLC. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services.

 

For Payment for Services: We may use and disclose protected health information about you so that the treatment and services you receive at Powered by Plants, LLC  may be billed to and payment may be collected from you.

For Health Care Operations: We may use and disclose protected health information about you for Powered by Plants, LLC health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer services and other activities. These uses and disclosures are necessary to make sure that all of our patients receive quality care. We may also combine generalized protected health information about many Powered by Plants, LLC patients to decide what additional services Powered by Plants, LLC should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to other Powered by Plants, LLC personnel for review and learning purposes.

 

As Required by Law: We will disclose protected health information about you when required to do so by federal, state or local law.

 

Health Risks: We may disclose protected health information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

 

Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health information about you 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, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.

 

Business Associates: We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to appropriately safeguard your information.

 

Public Health: As required 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 Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

 

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

 

Law Enforcement: We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.

Organ and Tissue Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.

 

Special Government Functions: If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans’ activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State.

Coroners, Medical Examiners, and Funeral Directors: We may release protected 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 disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.

 

Worker’s Compensation: We may disclose information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Food and Drug Administration: We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

 

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding protected health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy protected health

information that may be used to make decisions about you, you must submit your request in writing to Powered by Plants, LLC. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.

 

Right to Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information.

 

To request an amendment, your request must be made in writing and submitted to Brittany Summerlin, Powered by Plants, LLC. In addition, you must provide a reason that supports your request. We will act on the/ your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request and will provide a written denial to you. In addition, we may deny your request if you ask us 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 protected health information kept by Powered by Plants, LLC.

  • Is not part of the information which you would be permitted to inspect and copy, or

  • We believe is accurate and complete.

 

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Powered by Plants, LLC. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list.

We are required to provide a listing of all disclosures except the following:

  • For your treatment

  • For billing and collection of payment for your treatment

  • For health care operations

  • Made to or request by you, or that you authorized

  • Occurring as a byproduct of permitted use and disclosures

  • For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates

  • As part of a limited data set of information that does not contain information identifying you

 

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services. To request restrictions, you must make your request in writing to Powered by Plants, LLC.

 

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Powered by Plants, LLC. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time by contacting Powered by Plants, LLC.

 

OTHER USES AND DISCLOSURES

We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you believe your privacy rights have been violated, you may file a complaint with Powered by Plants, LLC or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way.

Acknowledgement Confirming Receipt of HIPAA Privacy Notice

I acknowledge I have received a copy of the HIPAA Privacy Notice. By typing your name and hitting submit you are agreeing that you have received this HIPAA notice and agree.