This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
If you have any questions about this notice, please contact our privacy officer:
Danika Viola
1035 Virginia Dr
Suite 140
Fort Washington, PA 19034
Flourish Pelvic Health & Wellness, LLC is required to:
• Maintain the privacy of protected protected health information
• Give you notice of your legal duties and privacy practices regarding protected protected health information about you
• Follow the terms of our notice that is currently in effect
How We May Use and Disclose Protected Health Information
Described as follows are the ways we may use and disclose protected health information that identifies you (“protected health information”). Except for the following purposes, we will use and disclose protected health information only with your written permission. You may revoke such permissions at any time by writing to our practice’s privacy officer.
Treatment. We may use and disclose protected health information for your treatment and to provide you with treatment-related health care services. This may include consulting with other health care providers about your health care and/or referring you to another health care provider including doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. For example, we may release your protected health information to a physician to whom you have been referred to ensure that the physician has the necessary information he or she needs to diagnose and/or treat you.
Payment. We may use and disclose Protected health information so that we or others may bill and receive payment from you, an insurance company, or a third party for treatment and services you receive. For example, we may give your health plan information so that they will pay for your treatment. The information on the accompanying the bill may include information that identifies you and your diagnosis, as well as services rendered, any procedures performed, and supplies used. We may also provide protected health information to a collection agency, small claims court or other court of competent jurisdiction in the event your claims for our services are not paid within 90 days and you have not made alternative payment arrangements with us,
Health Care Operations. We may use and disclose protected health information for health care operation purposes including, but not limited to, cost management, business planning, and accreditation activities. These uses and disclosures are necessary to make sure that all of our patients receive quality care to operate and manage our office. We also may share information with our entities that have a relationship with you (for example, your health plan) for their health care operation activities.
Students. Student/interns in occupational therapy or health service-related programs work in our facility from time to time to meet their educational requirements or to get health care experience. These students may observe or participate in your treatment or use your protected health information to assist in their training. You have the right to refuse to be examined, observed, or treated by any student or intern. If you do not want a student or intern to observe or participate in your care, please notify your provider.
Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services. We may use and disclose protected health information to contact you and remind you that you have an appointment with us. We also may use and disclose protected health information to tell you about treatment alternatives or health related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share protected health information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
Special Situations. We may use or disclose your protected protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Specifically, we may disclose your protected health information without your authorization in the following instances:
Business Associates. We may disclose Protected health information to our business associates that perform functions on our behalf or to provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specific in our contract.
Military and Veterans. If you are a member of the armed forces, we may use or release protected health information as required by military command authorities. We also may release protected health information to the appropriate foreign military authority if you are a member of a foreign military.
Public Health Risks. We may disclose protected health information for public health activities. These activities generally include disclosure to prevent or control disease, injury, or disability; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.
Health Oversight Activities. We may disclose protected health information 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.
Lawsuits and Disputes. If you are involved in a lawsuit of a dispute, we may disclose protected health information in response to a court or a court administrator order. We also may disclose protected health information 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 protected health information 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) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of crime even if, under certain 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 to the location of the crime if victims, or the identity, description, or location of the person who committed the crime.
Coroners, Medical Examiners, 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 release protected health information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release protected health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations. Protective Services and Intelligence Activities. We may release Protected health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or other custody of a law enforcement official, we may release Protected health information to the correctional institution or law enforcement official. This release would be made if necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others, or; 3) for the safety and security of the correctional institution.
Personal and Public Safety. We will disclose Protected health information when necessary to prevent a serious threat to your health and safety, or the public, or another person. Disclosure, however, will be made only to someone who may be able to help provide treatment or assistance.
Your Rights.
You have the following rights regarding protected health information we have about you:
Right to Inspect and Copy. You have the right to inspect and copy protected health information that we may used to make decisions about your care or payment for your care. This includes medical and billing records. To inspect and copy this information, you must make your request in writing, to our Privacy Officer.
Right to Amend. If you feel that protected health information 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 or for our office. To request an amendment, you must make your request, in writing, to our Privacy Officer.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of protected health information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our Privacy Officer.
Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose for treatment, payment, or health care operation. You also have a right to request a limit on the protected health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you can ask that we not share information about your particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to our Privacy Officer. We are not required to agree with your request. 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 your medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communications, you must make your request, in writing, to our Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You must 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 by contacting our office.
Changes to This Notice. We reserve the right to change this notice and make the new notice apply to protected health information we already have as well as any information we receive in the future. We will post a current copy of our notice at our office. The notice will contain the effective date on the first page, in the top right hand corner.
Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. To file a complaint with us, contact our Privacy Officer. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for filing a complaint.