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.
If you have any questions about this notice, please contact Solera Health’s Privacy Officer at: Privacy Officer, Solera Health, 111 West Monroe Street, Suite 300; Phoenix, AZ 85003; (602) 904-6108; email@example.com.
|WHO WILL FOLLOW THIS NOTICE|
This notice describes Solera Health’s privacy practices.
|OUR PLEDGE REGARDING MEDICAL INFORMATION|
We understand that confidential medical information about you (“you” or “your” used throughout refers to the patient) and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records received, used or disclosed by Solera Health. Non-Solera health providers may have different policies or notices regarding their uses and disclosures of your medical information.
This notice will tell you about the ways in which Solera Health may use or disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
|HOW 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 will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
We may use medical information about you to provide you with health care coordination and health management services. Our communications to you may be by telephone, cell phone, email, or mail. For example, we may use your information to facilitate appointment scheduling with your provider. We may disclose medical information about you to healthcare providers who are involved in taking care of you. We may also disclose medical information about you to people outside Solera Health who may be involved in your continued care, such as a disease management or prevention program.
We may use and disclose medical information about you so that the services you receive may be billed and payment collected from you, an insurance company or a third party, if applicable. For example, we may need information about your treatment history to facilitate benefits claims.
FOR HEALTH CARE OPERATIONS
We may use or disclose your health care information for health care operations. For example, we may use your information to determine the quality of care you received from one of our partners. If the activities require disclosure outside of our organization we will request your authorization before disclosing that information.
DISCLOSURE AT YOUR REQUEST
We may disclose information when requested by you. This disclosure at your request may require a written authorization from you.
TO INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE
We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.
In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
AS REQUIRED BY LAW
We will disclose medical information about you when required to do so by federal, state or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
We may use and disclose medical information to contact you as a reminder that you have an appointment for care.
We may use and disclose medical information to contact you to remind you about your attendance obligations.
PREVENTATIVE HEALTH AND HEALTH-RELATED BENEFITS AND SERVICES
We may use and disclose medical information to tell you about changes or lifestyle options or alternatives that may be of interest to you. We may also use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
VICTIMS OF ABUSE, NEGLECT, OR VIOLENCE
We may disclose your information to a government authority authorized by law to receive reports or abuse, neglect, or violence relating to children or the elderly.
MILITARY AND VETERANS
If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
PUBLIC HEALTH ACTIVITIES
We may disclose medical information about you for public health activities. These activities generally include the following:
HEALTH OVERSIGHT ACTIVITIES
We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws. We will only make this disclosure if you agree or when required or authorized by law.
LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
We may release medical information if asked to do so by a law enforcement official:
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS
We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose medical information about you to the correctional institution or law enforcement official. This disclosure would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.
MULTIDISCIPLINARY PERSONNEL TEAMS
We may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.
MARKETING AND SALE
Most uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of medical information, require your authorization. Solera Health will not disclose your health information for marketing or sale purposes without obtaining your authorization.
You may want to make contributions to support the services we provide. You have the right to opt out of receiving fundraising communications. If you receive a fundraising communication, it will tell you how to opt out.
SPECIAL CATEGORIES OF INFORMATION
In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information — e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program.
|YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU|
You have the following rights regarding medical information we maintain about you.
RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information.
To inspect and obtain a copy of medical information that may be used to make decisions about you, you must submit your request in writing to firstname.lastname@example.org. You have the right to request that the copy be provided in an electronic form or format (e.g., a PDF saved on a compact disk) if the information is readily producible in an electronic form or format. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
RIGHT TO AMEND
If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Solera Health.
To request an amendment, your request must be made in writing and submitted to email@example.com. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
RIGHT TO AN ACCOUNTING OF DISCLOSURES
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment and health care operations (as those functions are described above), and with other exceptions pursuant to the law.
To request this list or accounting of disclosures, you must submit your request in writing to firstname.lastname@example.org. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, 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.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the medical information we use or disclose about you for services, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about an evaluation you had.
We are not required to agree to your request, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for purposes of treating you.
If we agree to another special restriction, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to email@example.com. In your request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at home or by telephone.
To request confidential communications, you must make your request in writing to firstname.lastname@example.org. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, please contact our Privacy Officer at Privacy Officer, Solera Health, 111 West Monroe Street, Suite 300; Phoenix, AZ 85003, (602) 904-6108; email@example.com.
You may obtain an electronic copy of this notice at our website: www.soleranetwork.com
NOTIFICATION OF A BREACH
Solera Health will notify you as required by law following a breach of your unsecured protected health information.
|CHANGES TO THIS NOTICE|
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The notice will contain the effective date on the first page, in the top right-hand corner. In addition, each time you use our services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with Solera Health or the Secretary of the Federal Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
To file a complaint with Solera Health, contact: Privacy Officer at Privacy Officer, Solera Health, 111 West Monroe Street, Suite 300; Phoenix, AZ 85003, (602) 904-6108; firstname.lastname@example.org.
To file a complaint with the Department of Health and Human Services, contact: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave., S.W., Washington, D.C. 20201, or visit the Office for Civil Rights website to file a complaint electronically: http://www.hhs.gov/ocr/filing-with-ocr/index.html.
|OTHER USES OF MEDICAL INFORMATION|
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us 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, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.