NOTICE OF PRIVACY PRACTICES
(Effective November 19, 2020)
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.
We understand that health information about you and your health care is personal and are committed to protecting health information we receive about you. This notice will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you, that we receive from you or another source, that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. In this notice, we call all of that protected health information, “medical information.”
This notice also will tell you about your rights and our duties with respect to medical information about you. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
How We May Use and Disclose Medical Information About You
We use and disclose medical information about you for a number of different purposes. Each of those purposes is described below.
• For Treatment
We may use medical information about you to provide, coordinate or manage your related services by both us and health care providers we may communicate with. We may disclose medical information about you to doctors, nurses, hospitals and other health facilities who become involved in your care. We may consult with health care providers concerning you and as part of the consultation, share your medical information with them. Similarly, we may refer you to a health care provider and as part of the referral share medical information about you with that provider. For example, we may agree with you that you need to receive services from a provider with a particular specialty. When this happens, we may contact that provider’s office and provide medical information about you so they have information they need to provide services for you.
• For Payment
We may use and disclose medical information about you so we can be paid for the services we provide to you. This can include billing you, your insurance company, or a third-party payor. For example, we may need to give your insurance company information about the services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your medical condition and the health care you need to receive to determine if you are covered by that insurance or program. Currently, we only bill you for services that we provide.
• For Operations
We may use and disclose medical information about you for our own operations. These are necessary for us to operate and to maintain services for our patients. For example, we may use medical information about you to review the services we provide and the performance of our employees in caring for you. We may disclose medical information about you to train our staff, contractors, and agents working for IAMACOMBACK, LLC. We also may use the information to study ways to more efficiently manage our organization.
• How We Will Contact You
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate to you in a certain way or at a certain location, see “Right to Receive Confidential Communications” on page 7 of this Notice.
• Service Alternatives
We may use and disclose medical information about you to contact you about service alternatives that may be of interest to you.
• Health Related Benefits and Services
We may use and disclose medical information about you to contact you about health-related benefits and services that may be of interest to you.
• Marketing Communications
We may use and disclose medical information about you to communicate with you about a service. This may be:
• To describe a service that is provided by us;
• For a service that is provided to you by us;
• For services provided by us to assist you by doing such things as directing or recommending alternative treatments, therapies, health care providers or settings of care.
We may communicate to you about products and services in a face-to-face communication by us to you. We also may communicate about products or services in the form of a promotional gift of nominal value.
Any marketing of your medical information will be done only with your written authorization.
• Individuals Involved in Your Services
We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, medical information about you that is directly relevant to that person’s involvement with the services we provide or payment related to your services as long as you have been given an opportunity to agree, object or we can reasonably infer from the circumstances that you do not object. We also may use or disclose medical information about you to notify, or assist in notifying, those persons of your location, general condition, or death. If there is a family member, other relative, or close personal friend to whom you do not want to disclose medical information about you, please notify IAMACOMEBACK, LLC, or tell our staff member who is providing services to you.
• Required by Law
We may use or disclose medical information about you when we are required to do so by law and the disclosure complies with the requirements of such law.
• Public Health Activities
We may disclose medical information about you for public health activities and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease, injury or disability. It includes a public health authority or agency that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity. There are other public health authorities to whom we may report or disclose your medical information. The above are simply examples.
• Victims of Abuse, Neglect or Domestic Violence
We may disclose medical information about you to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is required by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims.
• Health Oversight Activities
We may disclose medical information about you to a health oversight agency, such as a state Department of Health and Human Services or a licensing agency for activities authorized by law, including audits, investigations, inspections, licensure, or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations. It is our understanding and belief that we currently are not subject to any oversight activities.
• Judicial and Administrative Proceedings
We may disclose medical information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal; however, we will only disclose the medical information expressly authorized by the court order. We also may disclose medical information about you in response to a subpoena, discovery request, or other legal process. In these cases, we will seek satisfactory assurances from the party seeking your medical information that you have been given notice or reasonable efforts have been made to secure a protective order on your behalf.
• Disclosures for Law Enforcement Purposes
Under certain circumstances, we may disclose medical information about you to a law enforcement official for law enforcement purposes. Some examples include the following: response to a court order, grand jury subpoena, administrative subpoena, court ordered warrant, or civil investigative demand; reporting certain types of wounds or injuries; or disclosures made due to crimes that occur on IAMACOMEBACK, LLC’s premises.
• Coroners and Medical Examiners
We may disclose medical information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death.
• Funeral Directors
We may disclose medical information about you to funeral directors as necessary for them to carry out their duties.
• Organ, Eye or Tissue Donation
To facilitate organ, eye or tissue donation and transplantation, we may disclose medical information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue.
• Research (if applicable)
Under certain circumstances, we may use or disclose medical information about you for research. Before we disclose medical information for research, the research will have been approved through an approval process that evaluates the needs of the research project with your needs for privacy of your medical information. We may, however, disclose medical information about you to a person who is preparing to conduct research to permit them to prepare for the project, but no medical information will leave IAMACOMEBACK, LLC during that person’s review of the information.
• To Avert Serious Threat to Health or Safety
We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.
• Specialized Government Functions
We may disclose medical information about you to authorized federal officials for national security reasons, including the conduct of intelligence, counter-intelligence, and other national security activities authorized by law. There are other permitted disclosures that may occur relating to matters of national security.
• Workers Compensation
We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
• Other Uses and Disclosures
Your written authorization will be obtained for: (a) most uses and disclosures of psychotherapy notes (to the extent that IAMACOMEBACK, LLC records or maintains these types of notes); (b) uses and disclosures of your medical information for marketing purposes; and, (c) disclosures that constitute a sale of your medical information. In addition, other uses and disclosures not described in this notice will be made only with your written authorization. You may revoke such an authorization at any time by notifying IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119, in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any effect on actions taken by us in reliance on it.
Your Rights With Respect to Medical Information About You
You have the following rights with respect to the medical information that we maintain about you.
• Right to Request Restrictions
You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) to public or private entities for disaster relief efforts. For example, you could ask that we not disclose medical information about you to your brother or sister.
As long as the disclosure is not required by law, you have the right to restrict the disclosure of your medical information to a health plan if the disclosure is being made for payment or health care operations purposes and you have already paid for the item or service in full out of pocket.
To request a restriction, you may do so at any time. If you request a restriction, you should do so in writing to IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. You should tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your sibling).
We are not required to agree to any requested restriction except your right to restrict disclosure of your medical information to a health plan as described above. However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.
• Right to Receive Confidential Communications
You have the right to request that we communicate medical information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail, at work or at a specific e-mail address or phone number. We will not require you to tell us why you are asking for confidential communication.
If you want to request confidential communication, you must do so in writing IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, when appropriate, require information from you concerning how payment will be handled. We also may require an alternate address or another method to contact you.
• Right to Inspect and Copy
You have the right to inspect and obtain a copy of medical information about you.
To inspect or copy medical information about you, you must submit your request in writing to IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. Your request should state specifically what medical information you want to inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.
We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.
We may deny your request to inspect and copy medical information if the medical information involved is information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding, or if we make determination that it can be denied under state or federal law.
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.
• Right to Amend
You have the right to ask us to amend medical information about you. This applies to information generated by IAMACOMEBACK, LLC. To change records generated by another entity (such as a physician), you must contact that entity.
You have this right for so long as the medical information is maintained by us.
To request an amendment, you must submit your request in writing to IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
If we grant the request, in whole or in part, we will seek your agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the medical information by appending or otherwise providing a link to the amendment.
We may deny your request to amend medical information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend medical information if we determine that the information:
• Was not created by us unless the person or entity that created the information is no longer available to act on the requested amendment;
• Is not part of the medical information maintained by us;
• Would not be available for you to inspect or copy; or,
• Is accurate and complete.
If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreement with our denial. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the medical information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the medical information involved.
You also will have the right to complain about our denial of your request.
• Right to an Accounting of Disclosures
You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting, but not before November 19, 2020. Certain types of disclosures are not included in such an accounting, which include, but are not limited to the following:
• Disclosures to carry out treatment, payment and health care operations;
• Disclosures of your medical information made to you;
• Disclosures that are incidental to another use or disclosure;
• Disclosures that you have authorized;
• Disclosures for our facility directory or to persons involved in your care;
• Disclosures for disaster relief purposes;
• Disclosures for national security or intelligence purposes;
• Disclosures to correctional institutions or law enforcement officials having custody of you;
• Disclosures that are part of a limited data set for purposes of research, public health, or health care
operations (a limited data set is where things that would directly identify you have been removed;
• Disclosures made prior to November 19, 2020.
Under certain circumstances, your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures, you must submit your request in writing to IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and may not include dates before November 19, 2020.
Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.
• Right to Copy of this Notice
You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even though you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time.
You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site, www.iamacomeback.com
To obtain a paper copy of this notice, contact IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119.
We are required by law to maintain the privacy of medical information about you and to provide individuals with notice of our legal duties and privacy practices with respect to medical information.
You have a right to receive notifications of any breach of your unsecured medical information. A breach of your unsecured medical information generally means that the medical information was used or disclosed in a way that was not permitted by law and the medical information was readable or decipherable by the unauthorized person or entity.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.
• Our Right to Change Notice of Privacy Practices
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the effective date of the new notice.
• Availability of Notice of Privacy Practices
A copy of our current Notice of Privacy Practices will be posted at our office as well as on our web site, www.iamacomeback.com.
At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119.
To file a complaint with us, contact IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119. All complaints should be submitted in writing.
You will not be retaliated against for filing a complaint.
• Questions and Information.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact IAMACOMEBACK, LLC, 7810 Goldenview Circle, Amarillo, TX 79119.