866-799-9619 | email@example.com
866-799-9619 | firstname.lastname@example.org
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA)
Effective Date: 5/1/16
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS COMPANY) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Highline Labs, LLC (the “Company”) is dedicated to maintaining the privacy of your protected health information (“PHI”). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our Lab concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices (the “Notice”) that we have in effect at the time. We will not use or share your information other than as described in this Notice unless you tell us we can in writing.
We realize that these laws are complicated, but we must provide you with the following important information:
The terms of this Notice apply to all records containing your PHI that are created or retained by our Company. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that our Company has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our Company will post a copy of our current Notice on our website, and you may request a copy of our most current Notice at any time.
Our Company may use your PHI for a number of different reasons. The following categories describe different ways in which we may use and disclose your PHI and provides some examples. While these examples do not include all of the specific ways we may use or disclose your health information, it will be for one of the reasons listed.
1. Treatment. We will use your PHI to provide you with laboratory services (also known as “treatment”). The Company’s employees, staff, and others whose work is under our direct control, may read your health information in order to provide those laboratory services. Additionally, subject to your objection, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.
2. Payment. Our Company may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, a Company employee may use your PHI to prepare a bill. The Company may send that bill, with any PHI it contains, to your health insurer for payment. We may disclose your PHI to other health care providers and companies to assist in their billing and collection efforts. Our Company may also use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members.
3. Health Care Operations. Our Company may use and disclose your PHI to perform the necessary administrative, educational, quality assurance and business functions of our company. As examples of the ways in which we may use and disclose your information for our operations, our Company may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our Company. We may disclose your PHI to other health care providers and entities involved in your care to assist with their health care operations.
4. Health-Related Benefits and Services. Our Company may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
5. Release of Information to Family/Friends. Our Company may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. We may make such disclosures when a) we have your verbal agreement to do so; b) we make such disclosures and you do not object; c) you are present at the time of the disclosure to another person and you do not object: d) we can infer from the circumstances that you would not object to such disclosures; e) or because if your incapacity is an emergency, the disclosure is in your best interest. We may also notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
We may also disclose your PHI to family members or friends in instances when you are unable to agree or object to such disclosures, provided that we feel it is in your best interests to make such disclosures and the disclosures relate to that family member or friend’s involvement in your care. If you are able to object to such disclosures, we will honor your request and will not disclose your information to family or friends.
6. Business Associates. We may disclose PHI to our business associates that perform functions on our behalf or provide us with services, if the health information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any health information other than as specified in our contract.
7. Disclosures Required By Law. Our Company will use and disclose your PHI when we are required to do so by federal, state or local law.
The following categories describe unique scenarios in which we may use or disclose your identifiable health information without your written authorization:
1. Public Health Risks. Our Company may disclose your PHI to public health authorities that are authorized by law to receive and collect health information for purposes of preventing or controlling disease, injury, or disability; to report births, deaths, suspected abuse or neglect, reactions to medications; or to facilitate product recalls. It may also include notifying people who have been exposed to a disease.
2. Health Oversight Activities. Our Company may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our Company may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if you have been informed of the request or there has been an effort to obtain a court or administrative order protecting the information the party has requested.
4. Law Enforcement. We may release PHI in response to a request received from a law enforcement official if asked by a law enforcement official if the health information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
5. Deceased Patients. Our Company may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our Company may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Our Company may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
8. Serious Threats to Health or Safety. Our Company may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
9. Military and National Security. Our Company may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. Our Company may disclose your PHI to federal officials for intelligence and national security activities authorized by law.
10. Protective Services for the President and Others. We may disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
11. Inmates. Our Company may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our Company may release your PHI for workers’ compensation and similar programs.
13. Data Breach Notification. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.
The Company may use or disclose your PHI for any purpose that is listed in this Notice without your written authorization. For any other situation not covered by this Notice or applicable law, we may not disclose your PHI without your written authorization. You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communications. You have the right to request that our Company communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request specifying the requested method of contact, or the location where you wish to be contacted. Our Company will accommodate reasonable requests.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to a request to restrict health information, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing. Your request must describe in a clear and concise fashion: a) the information you wish restricted; b) whether you are requesting to limit our Company’s use, disclosure or both; and c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including certain information designated by law. You must submit your request in writing in order to inspect and/or obtain a copy of your PHI. We have thirty (30) days to make your PHI available to you, and may get one thirty (30) day extension, and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. Our Company may charge a fee for the costs of copying, mailing, labor and supplies associated with your request, but we may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. Our Company may deny your request to inspect and/or copy PHI in certain limited circumstances. If we deny your request, we will provide you the reason for our denial in writing. For some of these circumstances, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor and supplies associated with transmitting the electronic medical record.
5. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Company. To request an amendment, your request must be made in writing, and you must provide us with the reason you believe the information is not correct or complete. Our Company will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the Company; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our Company, unless the individual or entity that created the information is not available to amend the information. The Company has sixty (60) days to respond to the request and may obtain one thirty (30) day extension.
6. Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your health information to others. An “accounting of disclosures” is a list of certain non-routine disclosures our Company has made of your PHI for non-treatment, non-payment or non-operations purposes. This accounting will not include certain disclosures of health information that we made, including disclosures to you or another person involved in your care for purposes of treatment, payment, or health care operations (except such disclosures made through an electronic health record in the 3 year period prior to the request), pursuant to a written authorization that you have signed, for national security or intelligence purposes, or to correctional institutions or law enforcement officials. In order to obtain an accounting of disclosures, you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The first list you request within a 12-month period is free of charge, but our Company may charge you for additional lists within the same 12-month period. Our Company will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
7. Right to Get a Notice of Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
8. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time.
9. Right to Provide an Authorization for Other Uses and Disclosures. Our Company will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the purposes described in the authorization.
10. Questions or Complaints. If you have any questions regarding this Notice or wish to receive additional information about our privacy practices, please contact our Privacy Officer at 980-256-5321. If you believe your privacy rights have been violated, you may file a complaint with our Company or with the Secretary of the Department of Health and Human Services. To file a complaint with our Company, contact the Privacy Officer at 5900 Northwoods Business Parkway, Suite K, Charlotte, NC 28269. All complaints must be submitted in writing. You will not be penalized for filing a complaint.