HIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices
This agreement was last modified on October 1, 2019.
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 terms of this Notice of Privacy Practices (“Notice”) apply to Belly & Soul, its affiliates and its employees. Belly & Soul will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.
Uses and Disclosures of Health Information
We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.
We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.
Understanding Your Health Information
Each time you visit a hospital, physician, or another healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided • A tool in educating health professionals
• A source of data for medical research
• A source of information for public health officials charged with improving the health of the nation • A source of data for facility planning and marketing
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:
• Ensure its accuracy
• Better understand who, what, when, where, and why others may access your health information
• Make more informed decisions when authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:
• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
• Obtain a paper copy of the notice of information practices upon request
• Inspect and obtain a copy of your health record as provided for in 45 CFR 164.524
• Amend your health record as provided in 45 CFR 164.528
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
• Request communications of your health information by alternative means or at alternative locations
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information.
This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information.
You may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other methods of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact. You may have the right to have your physician amend your protected health information.
This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 1, 2008. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions, and limitations.
You have the right to obtain a paper copy of this notice from us, upon request.
Belly & Soul is required to:
• Maintain the privacy of your health information
• Provide you with a notice as to our legal duties and privacy practices with respect to the information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us. We will not use or disclose your health information without your authorization, except as described in this notice.
Complaints: If you believe your privacy rights have been violated, you can file a complaint directly with Sharon Gray, LAc of Belly & Soul by calling (929) 322-3558. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint.
Office for Civil Rights Department of HHS
Jacob Javits Federal Building
26 Federal Plaza – Suite 3312
New York, NY 10278
Voice Phone (212) 264-3313
FAX (212) 264-3039
TDD (212) 264-2355
Disclosures for Treatment, Payment, and Health Operations
We will use your health-related information for the following procedures:
Example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your medical information will be shared among health care professionals involved in your care.
Example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.
Business associates: There are some services provided in our organization through contacts with business associates.
Example: We use a billing service to send claims to the insurance carriers and send statements to our patients. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with family: Health professionals, using their best judgment, may disclose to a family member, another relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Decedents: We may disclose health information to funeral directors, coroners, or medical examiner consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Fundraising: We may contact you as part of a fund-raising effort.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product, and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
For Further Information
If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the Belly & Soul Privacy Officer, Sharon Gray, LAc by phone at (929) 322- 3558 or at the following address:
Sharon Gray, LAc
Belly & Soul
P.O. Box 964
Twisp, WA 98856