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.
DialMD LLC, deemed as a covered entity under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), will be referred to in this Notice of Privacy Practices (“Notice”) as “CVR.” This Notice is created by CVR to describe the ways in which CVR may use and disclose your medical information (called “Protected Health Information” or “PHI”) and to notify you of your rights with respect to PHI in the possession of CVR. Pursuant to the Regulations, and as outlined in this Notice, CVR is permitted to use or disclose PHI to other parties. Below are categories describing these uses and disclosures, along with some examples to help you better understand each category.
Uses and Disclosures for Treatment, Payment and Health Care Operations
CVR may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining written authorization from you:
For Treatment: CVR may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities of other health care providers. These uses and disclosures may take place between physicians, nurses, technicians, and other health care professionals who provide or are otherwise involved in your health care. For example, your primary care physician may share your PHI with a specialist physician whom he/she consults regarding your condition, or to their staff who are assisting in the provision or coordination of your care.
For Payment: CVR may use and disclose PHI in order to bill and collect payment for health care services provided to you. For example, CVR may need to give PHI to your health plan in order to be reimbursed for the services provided to you. CVR may also disclose PHI to their business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. CVR may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans.
For Health Care Operations: CVR may use and disclose PHI as part of our health care operations, including: quality assessment and improvement, or evaluating the treatment and services you receive and the performance of its staff in caring for you. Other activities include provider training, compliance and risk management activities, planning and development, and management and administration. CVR may disclose PHI to doctors, nurses, technicians, attorneys, consultants, accountants, and others for review purposes. These disclosures help ensure that CVR is complying with all applicable laws, and are continuing to provide health care to patients at a high level of quality. CVR may also disclose PHI to other health care providers and health plans for certain of their operations, including their quality assessment and improvement activities, credentialing and peer review or compliance activities.
Sharing PHI Among CVR And Their Medical Staff
CVR locations work together with the physicians and other health care providers on staff to provide medical services to you when you are a patient at a CVR location. CVR and the members of its staff will share PHI with each other as needed to perform their joint treatment, payment and health care operations activities.
Other Uses and Disclosures for Which Authorization are Not Require
In addition to using or disclosing PHI for treatment, payment and health care operations, CVR may use and disclose PHI without your written authorization under the following circumstances:
As Required by Law and Law Enforcement: CVR may use or disclose PHI when required by law. CVR also may disclose PHI when ordered to in rare situations such as a judicial or administrative proceeding, in response to subpoenas or discovery requests, to identify or locate a suspect, fugitive, material witness, or missing person, about criminal conduct, to report a crime, its location or victims, or the identity, description or location of a person who committed a crime, or for other law enforcement purposes.
For Public Health Activities and Public Health Risks: CVR may disclose PHI to government officials in charge of collecting healthcare information, such as reactions to medications or product defects, or to notify persons who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.
For Health Oversight Activities: CVR may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other activities necessary for monitoring health care or compliance with government programs or civil rights laws.
Research: Under certain circumstances, CVR may use and disclose PHI for medical research purposes.
To Avoid a Serious Threat to Health or Safety: CVR may use and disclose PHI to law enforcement or other appropriate persons, to prevent or lessen a serious threat to the health/safety of a person or the public.
Specialized Government Functions: CVR may use and disclose PHI of military personnel and veterans under certain circumstances, and may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities.
Appointment Reminders, Health-related Benefits and Services, Limited Marketing Activities: CVR may use and disclose PHI to remind you of an appointment, or to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs. CVR may use and disclose your PHI to encourage you to purchase or use a product or service through face-to-face or written communication, or by giving you a promotional gift of nominal value.
Disclosures for HIPAA Compliance Investigations: CVR may disclose your PHI when required to do so in connection with your rights of access to your PHI and to account for certain disclosures of your PHI. CVR must disclose your PHI to the U.S. Department of HHS when requested by the Secretary in order to investigate compliance with privacy regulations issued under HIPAA.
Regulatory Requirements: CVR is required by law to maintain the privacy of your PHI, to provide individuals with notice of their legal privacy practice duties with respect to PHI, and to abide by the terms described in this Notice. CVR reserves the right to change the terms of this Notice or privacy policies, and to make changes applicable to all PHI it maintains. CVR will acknowledge Notice changes and make available a revised copy of the Notice upon the patient’s request. A copy of the Notice will be posted in registration and waiting areas.
You Have The Following Rights Regarding Your PHI: You may request that CVR restrict the use and disclosure of your PHI. CVR is not required to agree to any restriction requests, but will be bound to restrictions to which we agree, except in emergency situations. You have the right to request that communications of PHI to you from CVR be made by alternative means or locations. You may request that CVR can communicate with you by cellphone or via e-mail or to an alternate address. CVR can accommodate your request through completion of the CVR Communication Preferences and Message Agreement Form.
You have the right to inspect and copy your PHI in the possession of CVR, if you make a request in writing to the CVR Medical Records Director. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), CVR will inform you of the extent to which your request has or has not been granted. CVR may provide you a summary of the PHI you request if you agree in advance to such a summary. CVR may impose a reasonable fee determined by state law to cover copying, postage, and related costs for copies or summaries of your PHI. If CVR denies access to your PHI, it will explain the basis for denial. If CVR does not maintain the PHI you request, and it knows where that PHI is located, we will tell you how to redirect your request.
You have the right to receive notifications whenever a breach of your unsecured PHI occurs. CVR will provide notification through a written communication.
You have the right to restrict disclosure of information to your health plan(s) for services paid directly by you. You have the right to restrict the release of PHI for services for which you have paid for directly. Your written notification is required.
You have the right to designate personal representatives. You can designate specific individuals – other caregivers or personal representatives—with whom CVR may disclose your PHI. Please complete CVR’s Patient Privacy and HIPPA Protection Form.
You have the right to request that CVR amend, correct or supplement your PHI. Your request must be made in writing to the CVR Medical Records Director and it must explain why you are requesting an amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), CVR will inform you of the extent to which your request has or has not been granted. CVR generally can deny your request if your request relates to PHI: (i) not created by the entity; (ii) that is not part of the records the entity maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, CVR will give you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that future disclosures of the relevant PHI be made with a copy of your request and the entity’s denial attached; and (iii) complain about the denial.
You have the right to request/receive a list of PHI disclosures CVR has made during the six (6) years prior to your request (but not before April 14, 2003). The list will not include disclosures (i) for which you have provided a written authorization; (ii) for payment; (iii) made to you; (iv) to persons involved in your health care; (v) for national security or intelligence purposes; (vi) to law enforcement officials; or (vii) of a limited data set. You should submit any such request to the Privacy Officer, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), CVR will respond to you regarding the status of your request. CVR will provide you a list at no charge, but if you make more than one request in a year you will be charged a fee of $25.00 for each additional request.
You have the right to receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically. You can review and print a copy of this notice at any CVR Web site via https://mbcoaches.wpengine.com or you may request a paper copy of this notice by contacting the Privacy Officer as described below.
You may complain to CVR if you believe your privacy rights with respect to your PHI have been violated by contacting the Privacy Officer and submitting a written complaint, or contact the DialMD Hotline at (202) 921-4287. CVR will not retaliate against you for filing a complaint regarding their privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services.
If you have any questions about this notice, please contact the CVR Privacy Officer by phone at (202) 921-4287, by email at email@example.com, or by mail at 303 Twin Dolphin Dr Fl 6th, Redwood City, California, 94065-1497.
NOTICE IS EFFECTIVE: 5/1/2020