NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES (“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 respect your privacy and understand that your medical information is personal and sensitive. Moreover, we are required by law to comply with the HIPAA Privacy Rule which ensures medical information that identifies you is kept private. This Notice of Privacy Practices describes how we may use or disclose your protected health information at Life Change Medicine.

The Health Insurance Portability and Accountability Act of 1996, HIPAA Privacy Rule, establishes national standards to protect individuals’ medical records and other personal health information. The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information”, PHI, by organizations subject to the Privacy Rule — called “covered entities.” The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and wellbeing. The Rule also gives patient’s rights over their health information. This Act gives you the right to understand and in certain circumstances to control how your protected health information, PHI, is used.

We are required to give you this notice of our legal duties and abide by the terms of this notice, however, we may change all or part of our notice at any time. Please note that any new notice adopted will be effective for all protected health information maintained at the time of change. You will not be notified individually if a change is made to our notice, however, upon request, we will provide you with a copy of our current notice. You may always obtain a copy of our current notice by any of the following means:

1) Contacting our office by mail or by phone at the above address and phone number. 2) Asking for a copy at the time of your next visit.

Life Change Medicine protects the privacy of your medical information. To obtain a copy of your personal medical records, contact us at110 Lakeside Ave. Suite I Seattle, WA. 98122 Phone: (206) 331-7066. If you have questions concerning this notice, or would like further information please ask to speak to Dr. Meissner.

WHO WILL FOLLOW THIS NOTICE

This notice describes the practices of any health care professional at Life Change Medicine authorized to enter information in your medical record. This includes employees and contracted medical staff.

WHAT HEALTH INFORMATION IS PROTECTED

We are committed to protecting the privacy of information we gather about you while providing health-related services.  Some examples of protected health information are:

• information indicating that you are a patient or receiving treatment or other health-related services from us;
• information from other providers
• information about your health condition (such as your symptoms, test results, diagnoses, treatment you have had);
• information about health care products or services you have received or may receive in the future; or
• billing and payment information related to medical care and treatment, diagnostic and other medical services
• information about your health care benefits under an insurance plan;

      When combined with:

• demographic information (such as your name, address, or insurance status);
• unique numbers that may identify you (such as your social security number, your phone number, or your driver’s license number); or
• other types of information that may identify who you are.

OUR RESPONSIBILITIES

The law protects the privacy of the health information we create and obtain in providing care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information related to these services. Federal and state laws allow us to use and disclose your protected health information for purposes of treatment, payment, and health care operations.

REQUIREMENT FOR WRITTEN AUTHORIZATION

Except as authorized or required by law and as described in this Notice, we will obtain your written authorization before using your health information or sharing it with others outside Life Change Medicine. Uses and disclosures of health information that require your written authorization include:  most uses and disclosures of psychotherapy notes, most uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information.  Other uses and disclosures not described in this Notice or otherwise permitted by HIPAA will be made only with your written authorization.  You may also initiate the transfer of your records to another person by completing a written authorization form.  If you provide us with written authorization, you may revoke that written authorization at any time, except to the extent that we have already relied upon it.  To revoke a written authorization, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION

There are some situations when Life Change Medicine is allowed to use your health information or sharing it with others without your written authorization.  They are:

1. Treatment, Payment and Health Care Operations

We use and disclose your protected health information to carry out your treatment, obtain payment and conduct health care operations.

Life Change Medicine may use your health information or share it with others in order to provide health care services to you, obtain payment for those services, and run Life Change Medicine’s normal business operations.  Your health information may also be shared with your other health care providers so that they may jointly perform certain payment activities and business operations along with our medical practice.  In some cases, we may also disclose your health information for payment activities and certain business operations of another health care provider or payor.  Below are further examples of how your information may be used and disclosed for these treatment, payment, and normal business operations without your written authorization.

Treatment:  We will record information about you in your medical record for the purposes of deciding what care and treatment may be needed for you. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes disclosures to other third parties that are involved in your health care elsewhere. Specifically, we would disclose your protected health information to other physicians who may be treating you when we have the necessary permission from you to do so. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may occasionally disclose your protected health information to another physician or health care provider, such as a medical specialist or laboratory, who becomes involved in your care by providing assistance with your health care diagnosis or treatment. We may share your health information with health care providers at Life Change Medicine who are involved in taking care of you, and they may in turn use that information to diagnose or treat you.  A doctor in our practice may share your health information with another doctor inside our clinic, or with someone at another hospital or medical practice, to determine how to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. If Life Change Medicine at some future date becomes a preferred provider with your private insurer, this may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. In this case, we may share information about you with your health insurance company in order to obtain reimbursement after we have treated you.  In some cases, we may share information about you with your health insurance company to determine whether it will cover your treatment. For example, obtaining approval for coverage of future treatment with some medical modalities may require that your relevant medical information be disclosed to the health plan to obtain approval for future scheduling. Similarly, insurance companies may require that copies of your applicable medical records accompany any requests for payment of services already provided to you.

However, please note that Life Change Medicine does not currently accept private medical insurance or VA benefits and thus, will not bill your private insurer. To help defray costs, you can ask your insurer for reimbursement for our services. We can provide you with the necessary information that will allow you to submit a claim to your insurer yourself. Depending on the type of care you receive and the type of insurance you have, your insurer may reimburse you some portion of our services. In addition, we do offer a sliding fee and have a limited number of spaces allotted for those who have no coverage or who are underinsured or live just above the federal poverty line and thus do not qualify for health insurance subsidies under Obama care.

Health Care Operations:  We may use your health information or share it with others in order to conduct our business operations.  For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you.

We will share your protected health information with third party business associates that perform various activities—such as billing, collections, or records management—for the clinic. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your information.

Appointment Reminders, Treatment Alternatives, Benefits and Services.  We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment or services.  We may call you by your first name in the waiting room when ready to see you. For example, your name and address may be used to send you a newsletter about our clinic and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. We may contact you to provide you with information about upcoming fundraisers or other clinic services that may be of interest to you. If you do not wish to be contacted for these purposes, please call or write to our office at the address or phone number specified on page one.

Business Associates.  We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations.  For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company.  Another example is that we may share your health information with an accounting firm or law firm that provides professional advice to us about how to improve our health care services and comply with the law.  If we do disclose your health information to a business associate, we will have a written contract with our business associate that ensures that our business associate also protects the privacy of your health information.

 2. Friends and Family Involved In Your Care

If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care or with disaster relief agencies for such purposes as notification of family of your condition.

3. Emergencies or Public Need.

As Required By Law. We may use or disclose your health information if we are required by law to do so.  We also will notify you of these uses and disclosures if Notice is required by law.

Victims of Abuse, Neglect, or Domestic Violence.  We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence.

Health Oversight Activities- fraud, abuse detection and compliance programs.  We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our clinic. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.

Product Monitoring, Repair and Recall.  We may disclose your health information to a person or company that is regulated by the Food and Drug Administration for the purpose of: (1) reporting or tracking product defects or problems; (2) repairing, replacing, or recalling defective or dangerous products; or (3) monitoring the performance of a product after it has been approved for use by the general public.

Lawsuits and Disputes.  We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute.  We may also disclose your information in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure and only with a written certification by the party issuing the subpoena in accordance with law.

Law Enforcement.  We may disclose your health information to law enforcement officials for certain reasons, such as complying with court orders, subpoenas, assisting in the identification of fugitives or the location of missing persons, or if necessary to report a crime that occurred on our property or for other legal purposes.

To Avert a Serious and Imminent Threat To Health or Safety.  We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public.  In such cases, we will only share your information with someone able to help prevent the threat.  We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person, or if we determine that you escaped from lawful custody (such as a prison or mental health institution).

National Security and Intelligence Activities or Protective Services.  We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.

Military and Veterans.  If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission.  We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates and Correctional Institutions.  If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined.  This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.

Public Health Activities.  We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities under law, such as controlling disease or public health hazards.  We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so.  We may also release your health information to government disease registries.  And finally, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover that you have a work-related injury or disease that your employer must know about in order to comply with employment laws.

Workers’ Compensation.  We may disclose your health information for workers’ compensation or similar programs that provide benefits for work-related injuries.

Coroners, Medical Examiners and Funeral Directors.  In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner.  We may also release this information to funeral directors as necessary to carry out their duties consistent with applicable law.

Organ and Tissue Donation.  In the unfortunate event of your death, if you are an organ donor we will disclose your health information to organizations involved in organ donation, organ and tissue procurement and transplantation, as necessary to facilitate organ, tissue or eye donation and transplantation.

Research.  Under some circumstances, we may use and disclose your health information without your written authorization if we obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy.  Under no circumstances, however, would we allow researchers to use your name or identity publicly.  We may also release your health information without your written authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility.  In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.

Fundraising.  We are permitted to use your demographic information and dates of your health care for purposes of fundraising.  Fundraising is a communication from us or one of our business associates for the purpose of raising funds for our organization, including requests for donations or information about the sponsorship of events.  You have the right to choose not to receive future fundraising requests from us.  If you would prefer that we stop sending you fundraising materials, please follow the instructions included with each fundraising communication. Please, note that Life Change Medicine does not engage in fundraising activities at this time.

4. Completely De-identified or Partially De-identified Information. We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is “completely de-identified.”  We may also use and disclose “partially de-identified” health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law.  Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number).

5. Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information.  For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information.

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

Life Change Medicine want you to know that you have the following rights to access and control your health information.

1.  Right To Inspect and Copy Records. You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records.  This includes medical and billing records.  To inspect or obtain a copy of your health information, please submit your request in writing to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request.  Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information.  If we do, we will provide a written denial that explains our reasons for doing so, and a complete description of your rights to have that decision reviewed and how you can exercise those rights.

2. Right to Amend Records. If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is kept in our records.  To request an amendment, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101.  Your request should include the reasons why you think we should make the amendment.  If we deny part or all of your request, we will provide a written Notice that explains our reasons for doing so.  You will have the right to have certain information related to your requested amendment included in your records.

3. Right to an Accounting of Disclosures. You have a right to request an “accounting of disclosures,” which identifies certain other persons or organizations to whom we have disclosed your health information in accordance with applicable law and the protections afforded in this Notice.  Many routine disclosures we make will not be included in this accounting; however, the accounting will include many non-routine disclosures.

To request an accounting of disclosures, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101 and indicate a time period within the past six years for the disclosures you want us to include.  You have a right to receive one accounting within every 12 month period for free.  However, we may charge you for the cost of providing any additional accounting in that same 12 month period.

4. Right to Request Additional Privacy Protections. You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our business operations.  You may also request that we limit how we disclose information about you to family or friends involved in your care.  To request restrictions, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101. We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law.  However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law.  Once we have agreed to a restriction, you have the right to revoke the restriction at any time.  Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.  You have the right to restrict certain disclosures of protected health information to a health plan where you pay, or someone on your behalf has paid for out of pocket and in full.  You have the right to revoke the restriction at any time.

5. Right to Request Confidential Communications. You have the right to request that we contact you about your medical matters in a way that is more confidential for you, such as calling you at home instead of at work.  To request more confidential communications, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests.

6. Right to Have Someone Act on Your Behalf. You have the right to name a personal representative who may act on your behalf to control the privacy of your health information.  Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.

7. Right to Be Notified Following a Breach of Unsecured PHI. If you are affected by a breach of your unsecured protected health information, you have the right to, and will, receive notice of such breach.

8. Right To Revoke Written Authorization To Release Protected Health Information. You may also initiate the transfer of your records to another person by completing a written authorization form. If you provide us with written authorization, you may revoke that written authorization at any time, except to the extent that we have already relied upon it because the information has already been released.  To revoke a written authorization, please write to Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101.

9. Right to Object to Sharing You PHI with Friends and Family Involved In Your Care.

If object to us sharing your health information with a family member, relative, or close personal friend who is involved in your care, please provide Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101 with a written statement listing all persons with whom you wish to allow us to share your personal health information, PHI.

10. Right to Ask Questions about Our Privacy Practices. Please, feel free to ask for clarification concerning anything that is unclear to you about our privacy practices.  You can submit your questions either by phone at the number provided on page one of this notice or in person at your next office visit.

11. How to Learn About Special Protections for [HIV and Genetic Information]. Special privacy protections apply to [HIV test information, alcohol and substance abuse treatment information, mental health information, and genetic information].  Some parts of this general Notice of Privacy Practices may not apply to these types of information. To request copies separate Notices explaining how the information will be protected please contact Joie Meissner at 1214 Boylston Ave. Suite 306, Seattle, WA. 98101.

COMPLAINTS

12. Right to File a Complaint. If you believe your privacy rights have been violated, you may discuss your concerns with us at any time. You may file a complaint with our HIPAA Compliance Officer.  You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.

To file a complaint with us, please contact: Joie Meissner, HIPAA Compliance Officer, Life Change Medicine PLLC at: 1214 Boylston Ave. Suite 306, Seattle, WA. 98101; [(206) 331-7066].

We respect your right to file a privacy complaint. We will not retaliate or take action against you for filing a complaint. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. Any revised or changed notice will be effective for medical information we already have about you as well as any information we receive in the future. Life Change Medicine will post a copy of the current notice in our clinic and on our website  https://lifechangemedicine.com/notice-of-privacy-practices/  .

13. Right to Obtain a Copy of Notices. If this Notice is provided electronically, you have the right to a paper copy of this Notice, which you may request at any time. To do so, please call Joie Meissner at (206) 331-7066.  You may also obtain a copy of this Notice by requesting a copy at your next visit.  We may change our privacy practices from time to time.  If we do, we will revise this Notice so you will have an accurate summary of our practices.  We will post any revised Notice in our reception area.  You will also be able to obtain your own copy of the revised Notice.  The effective date of the Notice will always be noted in the top right corner of the first page.  We are required to abide by the terms of the Notice that is currently in effect.

 

Effective Date of this Notice: December 1, 2016