NOTICE OF PRIVACY PRACTICES
Your Information, Your Rights, Our Responsibilities
Pravan Health, LLC
Address: Cond. La Ciudadela, 1511 Juan Ponce de Leon Ave. Ste. 3 S.J. P.R. 00909
Privacy Officer: David Melchor
Telephone Number: 787-339-2639
Email Address: firstname.lastname@example.org
Effective Date: 4/25/19
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.
WHO WILL FOLLOW THIS NOTICE
- This Notice of Privacy Practices (the “Notice”) describes Pravan Health, LLC, (the “Company”/PRAVAN) practices and those of Company employees, staff, volunteers, and other personnel who are involved in your care. The Company and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services. Your personal Physician may have other policies that he or she follows if he or she sees you outside of the Company and may use his or her own Notice of Privacy Practices.
THE COMPANY’S PLEDGE REGARDING MEDICAL INFORMATION
- PRAVAN understands that medical information about you and your health is personal. PRAVAN is committed to protecting medical information about you. Health information that the Company receives and/or creates about you, personally, relating to your past, present, or future health, treatment, or payment for health care services, is “protected health information” under the federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164. In order to provide you with quality care and to comply with certain state and federal legal requirements, PRAVAN creates a record of the services you receive at our location. This Notice applies to all of the records of your care generated by PRAVAN. This Notice will tell you about the ways in which the Company may use and disclose medical information about you. It also describes your rights and certain obligations PRAVAN has regarding the use and disclosure of medical information. The Company is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect, and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
When it comes to your health information, you have certain rights. This section explains your rights and some of your responsibilities to help you.
- Right to Inspect and Copy:
- You can ask to see or obtain an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 5 days of your request. We may charge a reasonable, cost-based fee.
- Amendment to Your Information:
- If you feel that medical information about you is incorrect or incomplete, you may ask PRAVAN to amend the information. We will answer said request in the affirmative or negative in writing within 60 days of your request.
- Right to an Accounting of Disclosures:
- You have the right to receive a list of certain disclosures we may have made of your medical information.
- Right to Request Restrictions:
- You have the right to request a restriction or limitation on the medical information that PRAVAN uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that the Company may disclose to family members or friends involved in your care.
- Request Confidential Communications
- You have the right to request that PRAVAN communicates with you about your appointments or other matters related to your treatment in a specific way or at a specific location. We will say “yes” to all reasonable requests.
- Receive a Copy
- You have the right to obtain a copy of this notice.
- Right to File a Complaint:
- You can complain if you feel we have violated your rights by contacting us using the information provided.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights 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/.
- We will not retaliate against you for filing a complaint.
HOW THE COMPANY MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that PRAVAN may use or disclose protected
medical information. For each category of uses and disclosures, the Company will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways PRAVAN is permitted to use and disclose information will fall within one of the categories. Some information such as psychotherapy notes, certain drug and alcohol information, HIV, or mental health information is entitled to special restrictions.
- For Research:
- PRAVAN may disclose medical information about you to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.
- For Health Care Operations:
- PRAVAN may use and disclose medical information about you to carry out activities that are necessary for Company operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, PRAVAN may use medical information to review treatment and services provided at the Company or to evaluate the performance of its staff and contractors in caring for you.
- To Individuals or Family Members Involved in Your Health Care:
- Unless you object, PRAVAN may disclose medical information about you to a member of your family, a relative, a close friend or any other person that you identify who is involved in your care. The Company may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object. Please inform us of the person you authorize to disclose medical information.
- PRAVAN may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, PRAVAN will use its professional judgment to decide whether this disclosure is in your best interest.
- As Required by Law:
- PRAVAN will disclose your health information when required to do so by federal, state or local law.
- Workers Compensation:
- PRAVAN may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- For Public Health Activities:
- PRAVAN may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
- For Health Oversight Activities
- PRAVAN may disclose medical information about you to a health oversight agency for activities authorized by law.
- For Lawsuits and Disputes:
- PRAVAN may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
- Disclosure to Law Enforcement:
- If asked to do so by law enforcement and as authorized or required by law, PRAVAN may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at the Company; and (5) In case of a medical 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.
- PRAVAN may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. PRAVAN may also release medical information about you to funeral directors. PRAVAN may also release information to any individual known to PRAVAN as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
- For Specialized Government Functions:
- PRAVAN may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.
- Information About Inmates/Individuals in Custody:
- If you are an inmate or under the custody of a law enforcement official, PRAVAN may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
- Disclosure for Threats to Health and Safety:
- In certain circumstances, PRAVAN may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
- Marketing Purposes, Sale of Your Information:
- The Company will not release or sell your medical information for marketing purposes without an express written authorization from you.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.com
CHANGES TO THIS NOTICE
- PRAVAN reserves the right to change the terms of this Notice at any time. PRAVAN reserves the right to make the revised or changed notice effective for medical information PRAVAN already has about you as well as any information PRAVAN receives in the future. The Company will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
- If you have any questions or believe that your privacy rights have been violated, you may contact PRAVAN HIPAA Privacy Officer in person, by email or mail a written summary of your concern to the contact information provided
- You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
- Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide PRAVAN permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission PRAVAN will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if PRAVAN has already acted in reliance on your permission. You understand that PRAVAN is unable to take back any disclosure PRAVAN has already made with your permission and that the Company is required to retain its records of the care that the Company provided to you.