THIS NOTICE DESCRIBES HOW HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH AND MEDICAL INFORMATION IS IMPORTANT TO US.
OUR RESPONSIBILITIES
We at BeWell Rx LLC understand that medical information about you and your health is personal. Applicable federal and state law requires us to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect This Notice takes effect 03/14/2018 and will remain in effect until we replace it. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to mal<e the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we >made the changes. Before we mal<e a significant change in our privacy practice’s, we ..;11 change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES ANO DISCLOSURES OF HEAL TH INFORMATION
We may use and disclose health information about you for treatment, payment, and healthcare operations. For example:
To Treat You: We can use or disclose your health information to a physician or other healthcare providers providing treatment to you.
Billing and Payment for Services: We can use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We can use and disclose your health information in connection with our healthcare operations which include quality assessmen1 and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us
written authorization to use your health information or to disclose it to anyone for any purpose. II you give us an authorization, you may revoke it in writing at any time, your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you as described in the Patient.
Rights section of this Notice We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your healthcare or with payment for your healthcare, but only it you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity, or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is only relevant to the persons involvement in your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-Ray, or other similar health information.
Marketing Health Related Services. We will not use your health information for marketing purposes without your written consent.
Required by Law: We may use or disclose your health information when we are required to do so by state or federal law, including by the Department of Health and Human Services, if it wants to see that we are complying with federal privacy laws.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to acer a serious threat to your health or safety or the safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials’ health information required for lawful intelligence, counterintelligence, and other national security issues. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate patients under certain circumstances.
Respond to Organ and Tissue Donation Request: We can share health information about you with organ procurement organizations.
Work with a Medical Examiner or funeral director: We can share health information about you with coroner, medical examiner, or funeral director when an individual dies.
Address worker’s compensation, law enforcement, and other governmental requests: We can use or share your health information about you:
- For workers compensation claims.
- 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 protection activities.
Respond to lawsuits and legal activity: We can share health information about you in response to a court or administrative order, or response to a subpoena.
Appointment Reminders: We may use or disclose health information about you to provide you with appointment reminders (such as voicemail messages, postcards, texts, or letters)
PATIENT RIGHTS:
Access: You have the right to look at or get copies of your health information with limited exceptions. You may request that we provide copies of your health information in a format other than photocopies. We will use the format you request unless we can not practically do so. (You must make a request in writing to obtain access to your health information. You any obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies, mailing or staff time. You may also request access by sending us
a letter to the address at the end of this notice. If you request an alternative format, we will charge you a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of the fee structure.
Disclosure Accounting: You have the right to receive a list of the instances in which we or our business associates disclose your health information for the purposes, other than treatment, payment and healthcare operations and certain other activities, for the last 6 years, but not before April 14th, 2003. If you request this accounting more than once, in a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or alternative locations. ( You must make your request in writing) Your request must specify the alternative means or alternative locations, and provide satisfactory explanation how payments will be handled under the alternative means and locations you request.
Amendment:You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail) you are entitled to receive this notice in written form.
Questions and Complaints:
If you want more information about our privacy practices or have any questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate by alternative means or alternative locations, you may complain to us using the contact information at the end of the notice. You also may submit written complaint to the U.S. Department of Health and Human Services (DHHS) by sending a letter to 200 Independence Avenue, S.W., Washington D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
I have read and accepted this statement of confidentiality.
