Synergy: Mental Health & Wellness Integrated
THIS NOTICE IS REQUIRED BY LAW (FEDERAL REGULATION 45 CFR PARTS 160 & 164) AND DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THIS PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
WHO WILL FOLLOW THE PRIVACY PRACTICES IN THIS NOTICE
We provide health care to our patients. This Notice of Privacy Practices (“Notice”) describes how we will use and disclose medical information. The privacy practices described in this Notice will be followed by:
• Any member of our workforce authorized to access your medical record.
I. OUR COMMITMENT TO SAFEGUARD YOUR MEDICAL INFORMATION
Each time you visit our facility, a record of your visit is made. The information we create or receive about your past, present or future physical or mental health is called protected health information (“PHI”). Your medical record is a means of communication among the health professionals who care for you. PHI may include documentation of your symptoms, examination, test results, diagnoses, and treatment. It also includes documents related to billing and payment for care provided.
We are committed to protecting the privacy of your medical information. We are required by law to:
- maintain the privacy of your medical information;
- provide you with this Notice about our privacy practices that explains how, when, and why we use and disclose your PHI;
- abide by the terms of the current Notice;
- make a good faith effort to obtain your written acknowledgment that you have received this Notice; and
- notify you following a breach of your unsecured PHI.
II. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
This Notice informs you about the ways in which we may use and disclose medical information about you. The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we explain what we mean and give some examples to help you better understand the meaning. If a use or disclosure is not included in one of these categories, we will seek your permission first.
Uses and Disclosures Without Your Permission
The following categories describe different ways that we are permitted to use and disclose your medical information without your permission (which is called an “authorization” under HIPAA).
For Treatment. We may use and disclose your medical information to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, medical students, and other health care personnel who provide you with health care services or are involved in taking care of you. You may also be referred outside our facility for treatment and information will be shared to facilitate that referral.
For Payment. We may use and disclose your medical information to bill and collect payment for the treatment and services provided to you. This information may include your diagnoses, procedures and supplies used. For example, we may need to give your health insurance plan information about your visit so your health insurance plan will pay us for the visit. We may also contact your health insurance plan to obtain prior approval for treatment you are going to receive or to determine whether it is covered by your plan. We also may provide information about you to other health care providers that have treated you or provided services to you to assist them in obtaining payment.
For Health Care Operations. We may use and disclose your medical information for operations necessary for our facility to function and make sure our patients receive quality care. For example, we may use your medical information in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. This information may also be used in an effort to continually improve the quality and effectiveness of the health care and services we provide. We may disclosure your medical information to another health care provider or a health plan that you have a relationship with, for their operations’ activities.
Business Associates. We may disclose your medical information to other companies that help us. These business associates may include billing companies, claims processing companies, collection agencies, accountants, attorneys, consultants, and others that assist us with payment activities or health care operations. We contractually require our business associates to safeguard the privacy and security of your PHI.
Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a family member, personal representative, or other person involved in your care or responsible for payment of your health care services. We may also discuss your condition with your family or friends. If you do not want us to share information with your family or others involved in your care, please contact the person listed in Section V of this Notice.
Food and Drug Administration (FDA). We may disclose your medical information to a person or company subject to the jurisdiction of the FDA to report adverse events, product defects or problems or biologic product deviations; to track FDA-regulated products; to enable product recalls; or for other purposes related to the quality, safety or effectiveness of a product or activity regulated by the FDA.
Public Safety. We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, and to report criminal conduct at the facility. We also may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety. Judicial and Administrative Proceedings. We may disclose medical information if we are ordered to do so by a court, for an administrative hearing, or if we receive a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations so that you will have a chance to object to sharing your medical information.
Coroners, Medical Examiners and Funeral Directors. We may disclose health information consistent with applicable law to coroners, medical examiners, and funeral directors to assist them in carrying out their duties.
Research. Under certain limited circumstances, we may use and disclose your medical information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who receive one medication to those who receive another for the same condition. All research projects are subject to a special approval process. Before we use or disclose medical information for research, the project will have been approved through this research approval process.
Reports Required by Law. We will disclose your medical information when required to do so by federal, state, or local law. For example, we make disclosures when a law requires that we report information to government agencies and/or law enforcement personnel about victims of abuse, neglect, or domestic violence; to report reactions to medications or problems with products; or to notify people of product recalls.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure.
Workers’ Compensation. We may disclose your medical information to the extent necessary to comply with laws relating to workers’ compensation or similar programs providing benefits for work-related injuries or illness.
Military, Veterans, National Security and Other Government Purposes. If you are a member of the armed forces, we may release your health information to military command authorities or to the Department of Veterans Affairs if they require us to do so. We may also disclose medical information for certain national security purposes and to the Secret Service to protect the president. Correctional Institutions. If you are or become an inmate of a correction institution or under the custody of a law enforcement official, we may disclose your medical information to the correctional institution or law enforcement official. This disclosure may be necessary for the institution (i) to provide you with health care; (ii) to protect your health and safety or the health and safety of others; or (iii) for the safety and security of the correctional institution.
Appointment Reminders. We may use or disclose your medical information to provide you with appointment reminders, such as voicemail messages, postcards, or letters.
Laboratory/Pathology/Culture Results. All patients are attempted to be notified of their results by telephone. It is your ultimate responsibility to call our office for your results if we are unable to reach you
Uses and Disclosures Requiring Your Permission
Other uses and disclosures of medical information not covered by this Notice will be made only with your written permission. If you provide us
permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we
will no longer use or disclose medical information about you for the reasons covered by your written authorization, but we cannot take back any
disclosures we have already made based on the permission you gave us before. If you want to revoke your permission, please contact the person listed in
Section V of this Notice.
Marketing Activities. We will not use or disclose your PHI to sell you products or services to a third party unless you provide permission. We may suggest
products or services to you during our face-to-face communications.
Sale of PHI. We will not sell your PHI to third parties without your permission.
Medical Information That Has Special Protection
Mental Health Records. The use and disclosure of information obtained in the course of providing mental health services are protected by federal and
state laws. We may communicate information for treatment purposes to qualified professionals, for payment purposes or if we receive a court order.
Otherwise, we may not disclose any of your mental health information without your permission.
Alcohol and Drug Abuse Patient Records. Use and disclosure of any medical information about you relative to alcohol or drug abuse treatment
programs, is protected by federal law. Generally, we will not disclose any information identifying you as a recipient of alcohol or drug abuse treatment
unless: (i) you have consented in writing; (ii) we receive a court order requiring the disclosure; or (iii) the disclosure is made to medical personnel in a
medical emergency or to qualified personnel for research, audit, or program evaluation.
HIV/AIDS Information. Use and disclosure of any medical information about you relative to HIV testing, HIV status, or AIDS, is protected by federal and
state law. Generally, we will need your permission to disclose this information; however, state law may allow for disclosure of information for public
health purposes.
Minors. As a general rule, we disclose PHI about minors to their parents or legal guardians. However, in instances where state law allows minors to
consent to their own treatment without parental consent (such as HIV testing), we will not disclose that information to a minor’s parents without the
minor’s permission unless otherwise specifically allowed under state law.
III. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
The following section describes your rights:
The Right to Inspect and Obtain a Copy of Your Medical Information. You have the right to see and receive a paper or electronic copy of medical
information, with limited exceptions. (The law requires us to keep the original record.) Usually, this includes your medical and billing records. To inspect
and/or receive a copy of your medical information, you must make a request in writing. If you request a copy of the information, we may charge you $25.00.
If your records are transferred to another physician, there is no fee charged.
The Right to Amend. If you believe that medical information, we have about you is incorrect or incomplete, you have the right to request that we correct
the existing information or add missing information. To request an amendment, you must make the request in writing along with your reason for the
request to the person listed in Section V below.
The Right to a List of Disclosure. You have the right to request a list of certain disclosures of your medical information. To request this list or accounting
of disclosures, you must submit a request in writing indicating a time period, for the past 6 years to the person listed in Section V below. The first list you
request within a 12-month period will be free. For additional lists during the same year, we may charge you for the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
The Right to Request Restrictions on How We Use and Disclose Your Medical Information. You may ask us not to use or disclose your medical
information for a particular reason related to treatment, payment, or health care operations. We will consider your request, but we are not legally
obligated to agree to a requested restriction except in the following situation: if you have paid for services out-of-pocket in full, you may request that we
not disclose information related solely to those services to your health plan.
We are required to abide by such a request, except where we are required by law to make the disclosure. To request restrictions on the use or
disclosure of your PHI, you may do so at the time you register for services or by contacting the person listed in Section V below.
The Right to Request Confidential Communications. You have the right to ask that medical information about you be communicated to you in an
alternate confidential manner, such as asking that appointment reminders not be left on an answering machine, that mail be sent to an alternate address,
or that notices or reminders be sent by e-mail instead of regular mail. We will agree to all reasonable requests so long as we can easily provide it in the
format you request. To request medical information be sent to an alternative address or by other means, please contact the person listed in Section V
below in writing, or in a clinic setting, please contact the practice manager.
The Right to Breach Notification. You have the right to be notified in the event of a breach in the privacy or security of your protected health information.
IV. COMPLAINTS
If you believe that we may have violated your rights with respect to your medical information, you may file a written complaint with the person listed in
Section V below. You also may send a written complaint to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence
Avenue S.W., Room 515F, HHH Building, Washington, D.C. 20201 within 180 days of an alleged violation of your rights. You will not be penalized for filing a
complaint about our privacy practices. You will not be required to waive this right as a condition of treatment.
V. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you have any questions about this Notice or wish to make a complaint about our privacy practices, please contact our Privacy Officer at (480) 508-0882. Formal complaints must be in writing to ATTN: Privacy Officer, Synergy Mental Health & Wellness Integrated, 8350 Raintree Dr. Suite 130, Scottsdale, AZ, 85260.
VI. CHANGES
We reserve the right to change the terms of this Notice and our privacy policies at any time. We reserve the right to make the revised Notice effective for medical information we already have about you as well as any information we receive in the future. Before we make an important change to our policies, we will promptly change this Notice and post a new Notice in our registration area. The Notice will contain the effective date. You can also request a copy of this Notice from the contact person listed in Section V.
VII. ACKNOWLEDGMENT
We are required by law to make a good faith effort to provide you with our Notice of Privacy Practices. Your continued use of our site will be considered an acknowledgment from you that you received.