The law requires us to:
It is our policy to keep all information about you confidential in all settings. It is so important to us that we take the following steps:
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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Global Pain Center Corp. d/b/a/ Override (referred to as “Override”) and Merion Square Road Medical P.C. d/b/a/ Override (referred to as “Override”), are Pennsylvania-based companies providing administrative and clinical services.
Our Commitment To Your Privacy: We understand that medical information about you and your health is personal. We are committed to safeguarding your PHI. PHI is any information that can identify you as an individual and your past, present, or future physical or mental health condition. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
Our legal duty: Override is required by applicable federal and state laws to maintain the privacy of your PHI. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning PHI. We must follow the privacy practices that are described in this notice while it is in effect. This Notice of Privacy Practices has an Effective Date of 08/03/2022. We reserve the right to change our privacy practices and the terms of this notice at any time, provided that applicable law permits such changes. The new terms of our notice are effective for all PHI that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and send the new notice to you at the time of the change. You may request a copy of our notice at any time. We are required to notify you within 60 days of discovery of a breach in accordance with the Breach Notification Rule - 45 CFR Part 164 SubPart D (164.400 - 164.414). This notification would be via certified mail.
Uses and Disclosures of Nonpublic Personal Information: Nonpublic Personal Information is information you give us during your enrollment, initial assessment, etc. For example: names, member identification number, addresses, type of health care benefits, payment amounts, etc. We will not give out your nonpublic personal information to anyone unless we are permitted to do so by law or have received a signed authorization form from you. You may revoke this authorization in writing by completing an authorization cancellation form at any time. This revocation will not affect any action Override took in reliance on your authorization before your authorization cancellation form was processed.
Uses and Disclosures of Medical Information: The following categories describe different purposes for which we use and disclose PHI. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. If we need to use or disclose your PHI in any other way, we will obtain your signed authorization before our use or disclosure. You may revoke this authorization in writing by completing an authorization cancellation form at any time. This revocation will not affect any actions Override took in reliance on your authorization before your authorization cancellation form was processed.
Treatment: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may disclose PHI to health care providers, including doctors or hospitals involved in your care. For example, we may disclose your medications to an emergency room physician so that he/she/they can avoid dangerous drug interactions. This allows providers to manage, coordinate and administer treatment.
Payment: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may use and disclose PHI to collect payment for services. We may also disclose PHI to insurance companies to coordinate the reimbursement of health insurance benefits. For example, if you provide us with health insurance information through an additional insurance company, we may disclose PHI to that other health insurance company in order to determine which company holds the responsibility for your claims.
Healthcare Operations: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may use and disclose PHI for purposes of performing our healthcare operations. Our healthcare operations include using PHI to determine fees to conduct quality assessment and improvement activities, to engage in care coordination or case management, to determine eligibility for benefits. For example, we may use or disclose PHI when working with accreditation agencies that monitor and evaluate the quality of our programs.
To You: We must disclose your PHI to you, as described in the Individual Rights section of this notice, below. We may also use and disclose PHI to tell you about recommended possible treatment options or alternatives or to tell you about health-related benefits or services that may be of interest to you.
Questions and Complaints: If you are concerned that we may have violated your privacy rights, as described within this document, or you disagree with a decision we made about access to your PHI or in response to a request you made to amend or restrict the use or disclosure of your PHI or to have us confidentially communicate with you at an alternative location, you may complain to us using the contact information at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to protect the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Privacy Rights or Questions: Contact: Call Center Phone: 646-598-8338 Privacy Complaints: Contact: 944 Gladwyne, PA 19035 Email: email@example.com.
To Family and Friends: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. If you agree or, if you are unable to agree when the situation, (such as medical emergency or disaster relief), indicates that disclosure would be in your best interest, we may disclose PHI to a family member, friend or other person. In an emergency situation, we will only disclose the minimum amount necessary.
To Our Business Associates: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. A business associate is defined as someone that assists us in managing our business. We may disclose PHI to another company that helps us manage our business. For example, we may disclose PHI to a company that manages our electronic health record. These business associates are required to sign a business associate agreement with us that limits their use or disclosure of the PHI they receive.
To Plan Sponsors: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. A plan sponsor is defined as the employer or employee organization that establishes and maintains the employee’s benefit plan. If you are enrolled in a group health plan, we may disclose PHI to the plan sponsor to permit the plan sponsor to perform plan administrative functions. For example, the cost analysis of the benefit program. Before PHI is disclosed to your plan sponsor, we will receive certification from the plan sponsor that appropriate amendments have been made to group health plan document(s) and the plan sponsor agrees to limit their use or disclosure of this information to plan administration functions only.
Research: We may use or disclose de-identified participant data for retrospective analysis of program effectiveness. All prospective research projects require a separate consent in addition to this general notice.
Public Health and Safety: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may disclose PHI to the extent necessary to avert a serious and imminent threat to your health or safety, or the health or safety of others. We may disclose PHI to a government agency authorized to oversee the healthcare system or government programs or its contractors, and to public health authorities for public health purposes.
Victims of Abuse, Neglect or Domestic Violence: We may disclose PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes.
Required by Law: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may use or disclose PHI when we are required to do so by law. For example, we must disclose PHI to the U.S. Department of Health and Human Services upon request to determine whether we are in compliance with federal privacy laws.
Process and Proceedings: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may disclose PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may disclose PHI to law enforcement officials.
Law Enforcement: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may disclose PHI to a law enforcement official investigating a suspect, fugitive, material witness, crime victim or missing person. We may disclose PHI of an inmate or other person in lawful custody of a law enforcement official or correctional institution under certain circumstances.
Military and National Security: We will not disclose PHI to an unauthorized person not involved in your care or treatment, unless we are required or permitted to do so by law. We may disclose to the military, PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials medical information required for lawful intelligence, counterintelligence, and other national security activities.
Individual Rights Access: You have the right to inspect and/or copy your PHI, with limited exceptions such as information a licensed health care professional, exercising professional judgment, determines that providing access is reasonably likely to endanger the life, physical safety or cause someone substantial harm.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your PHI. The list will not include disclosures we made for the purpose of treatment, payment, healthcare operations, disclosures made with your authorization, or certain other disclosures. To request a disclosure accounting, you may contact us using the contact information at the end of this notice. You may request an accounting of disclosures and the request may not exceed a six year time period. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your PHI, a description of the PHI we disclosed and the reason for the disclosure.
Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. As permitted by law, we will not honor these requests, if it prohibits us from administering your benefits.
Confidential Communication: You have the right to request that we communicate with you confidentially about your PHI. We will honor a request to communicate to an alternative location if you believe you would be endangered if we do not communicate to the alternative location. We must accommodate your request if it is reasonable and specifies the alternative location.
Amendment: You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or if we determine the information is accurate. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be attached to the information you wanted amended.
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.
HIPAA NOTICE OF PRIVACY PRACTICES
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 Override.
OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION: We, Override understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all of the records of your care generated by Override, whether made by Override personnel or your personal doctor or other health care provider. 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. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. Override staff may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside Override’s office who may be involved in your medical care. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Override. 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 Override may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about nutrition services you received at Override so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose protected health information about you for Override 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 run the facility, reduce health care costs, and make sure that all of our patients receive quality care. We may also combine protected health information about many Override patients to decide what additional services Override should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Override personnel for review and learning purposes. We may also combine the protected health information we have with protected health information from other health care facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study healthcare and health care delivery without learning who the specific patients are. We may also contact you as part of a fundraising effort. Subject to applicable state law, in some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our facilities.
As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law. Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. 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.
YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances: We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death. We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances. If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.
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 Override. 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 Override. 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 Override 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 Override. 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 requested 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, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing to Override.
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 Override. 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 Override. 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 Override, 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. Please sign and date below.