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.
If you have any questions about this notice, please contact the Privacy Officer at firstname.lastname@example.org.
Your Information, Your Rights, Our Responsibilities
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Latitude Food Allergy Care. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Latitude Food Allergy Care.
This notice describes how we may use and disclose medical information about you. We also describe your rights to access this information and certain obligations we have regarding the use and disclosure of medical information. Please review this notice carefully.
How Latitude Food Allergy Care May Use and Disclose Health information About You
The following categories describe different ways that we use and disclose health information. 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 every category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
- DISCLOSURE AT YOUR REQUEST – We may disclose health information about you when requested by you. This disclosure at your request may require a written authorization by you.
- FOR TREATMENT – We may use and disclose health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, or other clinic personnel who are involved in taking care of you at Latitude Food Allergy Care. We also may disclose health information about you to people outside the clinic who may be involved in your medical care after you leave the clinic, such as hospitals, physicians or other practitioners. For example, we may give your primary care physician access to your health information to assist your physician in treating you.
- FOR PAYMENT – We may use and disclose health information about you so that the treatment and services you receive at Latitude Food Allergy Care 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 information about care you received at Latitude Food Allergy Care to your health plan so it will pay us or reimburse you for the care provided. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside Latitude Food Allergy Care who are involved in your care, to assist them in obtaining payment for services they provide to you. However, we cannot disclose information to your health plan for payment purposes if you ask us not to, and you pay for the services yourself.
- FOR HEALTH CARE OPERATIONS – We may use and disclose health information about you for health care operations. These uses and disclosures are necessary to run Latitude Food Allergy Care and make sure that all of our patients receive quality care. For example, we may use health information about you to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many of our patients to decide what additional services the clinic should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose health information about you to doctors, nurses, and other clinic personnel for review and learning purposes.
- AS REQUIRED BY LAW – We will disclose health information about you when required to do so by federal, state or local law.
- INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE – We may release health information about you to a friend or family member who is involved in your medical care. We may also give your information to someone who helps pay for your care.
- MARKETING AND SALES – Most uses and disclosures of health information for marketing purposes, and disclosures that constitute a sale of health information, require separate authorization from you.
- RESEARCH – Under certain circumstances, we may use and disclose health information about you for research purposes. In addition to disclosing aggregated and de-identified health information for research purposes, we may also disclose your health information to researchers when an Institutional Review Board (“IRB”) or Privacy Board has determined, that there is minimal risk to you, and your express consent is not required. We may also contact you, using the contact information you have provided to us, regarding your interest in participating in certain research studies. You will only become a part of a research study if you agree to do so and sign a specific permission form called an “Authorization.”
- TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY – We may use and disclose 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.
- APPOINTMENT REMINDERS AND CALL BACKS – We may use and disclose health information to contact you as a reminder that you have an appointment for care at Latitude Food Allergy Care. We will communicate with you using the information (such as telephone number and email address) that you provide. Unless you notify us to the contrary, we may use the contact information you provide to communicate general information about your care, such as appointment location, department, date and time.
- BUSINESS ASSOCIATES – Latitude Food Allergy Care contracts with outside entities that perform business services for us, such as billing companies, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your health information with a business associate so it can perform a service on our behalf. We will have a written contract in place with the business associate requiring protection of the privacy and security of your health information.
- HEALTH OVERSIGHT ACTIVITIES – We may disclose health information about you to a health oversight agency for activities required 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.
- LAW ENFORCEMENT – We may release health information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the clinic;
- In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
- LAWSUITS AND DISPUTES – If you are involved in a lawsuit or a dispute, we may disclose health information about you 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 to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
- PUBLIC HEALTH ACTIVITIES – We may use or disclose health information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability;
- To report suspected abuse, neglect, or domestic violence;
- To report reactions to medications or problems with products; or
- To notify people of recalls of products they may be using.
- TREATMENT ALTERNATIVES – We may use or disclose your health information to tell you about or recommend possible treatment-related options, activities or alternatives that may be helpful to you.
Your Rights Regarding Health information About You
You have the following rights regarding health information we maintain about you.
- RIGHT TO INSPECT AND COPY – You have the right to inspect and obtain a copy of your medical record and other health information we have about you. Usually, this includes medical and billing records. You may submit your request in writing to Latitude Food Allergy Care’s Privacy Officer and we will provide the copy usually within 30 days of your request. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
- RIGHT TO AMEND – If you feel that health information we have about you 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 Latitude Food Allergy Care. Your request must be made in writing and submitted to Latitude Food Allergy Care’s Privacy Officer. In addition, you must provide a reason that supports your 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. If we deny your request, we will tell you in writing within 60 days.
- RIGHT TO AN ACCOUNTING OF DISCLOSURES – You have the right to request an “accounting of disclosures.” This is a list of the times we shared health information about you other than our own uses for treatment, payment and health care operations (as those functions are described above), and with other exceptions pursuant to the law, with whom, and why. To request this list or accounting of disclosures, you must submit your request in writing to Latitude Food Allergy Care’s Privacy Officer. Your request must state a time period, which may not be longer than six years prior. Your request should indicate in what form you want the list (for example, on paper or electronically). 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 will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- RIGHT TO REQUEST RESTRICTIONS – You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for the purposes of treating you. If we agree to another special restriction, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Latitude Food Allergy Care’s Privacy Officer. In your request, you must tell us: 1) What information you want to limit; 2) Whether you want to limit our use, disclosure or both; and 3) To whom you want the limits to apply; for example, disclosures to your spouse.
- 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 Latitude Food Allergy Care’s Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- RIGHT TO A PAPER COPY OF THIS NOTICE – You have the right to a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. You may ask us to give you a copy of this notice at any time.
Filing a Complaint If You Feel Your Rights are Violated
If you believe we have violated your privacy rights, you may file a complaint with Latitude Food Allergy Care’s Privacy Officer via email@example.com.
You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services 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.
Other Uses of Health information
Other uses and disclosure of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your health information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to 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.
Changes to The Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
This notice is effective as of August 7, 2018.