NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices may contain words you do not understand.  If you have any questions, please ask your treating physician, your Monogram Health Program staff or provider, or contact Monogram Health’s Privacy Office at compliance@monogramhealth.com or 1-855-212-2273 (TTY 711).

Our Commitment to You

Your health information is personal. We are committed to protecting health information about you. We will create a record of the care and services you receive. This record will document the quality of care provided to you and will meet the requirements of federal and state laws and regulations. This Notice of Privacy Practices applies to all the records of your care given by Monogram Health, Inc., its affiliates, and Monogram Kidney Care, and its affiliates (“Monogram Health”), and by any of Monogram Health’s providers, employees, personnel, staff members and contractors described below.

By law, we must:

§  Keep health information about you private;

§  Give you this Notice of Privacy Practices informing you of our legal duties to keep your health information private; and

§  Follow the current requirements of the Notice of Privacy Practices in effect.

How Your Health Information May be Used

We may use and disclose your health information without your consent:

§  For Program Services, such as sending health information about you to your primary care physician as part of care management services or to another doctor as part of a referral.  We may also share your health information in order to coordinate different aspects of care that you need.  We may disclose your health information to people who provide services in connection with your health care;

§  To obtain payment for treatment provided, such as sending billing info to your insurance company or Medicare;

§  For our healthcare operations, such as quality assessment and improvement activities, case management, business planning, customer services, and other activities.  For example, we may use your information to compare your data to another patient’s data to improve our services or treatment methods,

Please note: This means we may share your psychiatric or HIV information if needed for purposes of diagnosis or treatment. The psychiatric or HIV information disclosed for billing purposes will be kept to a limited amount. Unless its an emergency, if you receive treatment in a specialized substance abuse program, we will not share that information without a special authorization from you.

We may also use and disclose your health information without your consent:

§  For public health purposes: We may disclose your health information to public health authorities for the purposes of controlling the spread of disease.  For example, we may disclose to local public health authorities if you test positive for Ebola or, in a disaster, we may share your health information with relief authorities so that your family can be notified of your location and health condition.

§  For abuse or neglect reporting: We may disclose your health information to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence.  We will disclose this type of information only to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

§  For health oversight audits or inspections: We may disclose your health information in the event of an audit or investigation of our organization by a local, state or federal agency.

§  To Medical Examiners or for funeral arrangements or organ donation: We may disclose your health information as needed to determine the cause of death or to allow for funeral arrangements to be made on your behalf.

§  For Workers’ Compensation purposes: We may disclose your health information as required by Workers’ Compensation laws or other similar programs.  For example, we may disclose your health information to Workers Compensation authorities regarding work-related injuries.

§  For Emergencies: Unless you specifically request a restriction before you are incapacitated, we may use or disclose your health information during a period of your incapacitation, if we determine, using our professional judgment, the use or disclosure is in your best interest.

§  For national security or other specialized government functions: We may disclose your health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by the National Security Act. For example, we may disclose your health information to provide protective services to the President or other important officials.

§  For members of the Armed Forces as required by Military Command authorities: If you are a member of the United States Armed Forces, we may disclose your health information to appropriate military command authorities.  For example, we may disclosure your health information to appropriate command authorities so they can determine your fitness for duty or for a particular assignment.

§  To respond to a request from law enforcement in specific circumstances: We may disclose your health information to law enforcement to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public.

§  In response to a valid judicial or administrative order or other legal process.

On a separate form, you may list the names of friends and family that we can share your health information in appropriate circumstances.

We may also use information about you to:

§  Remind you about an appointment;

§  Tell you about possible treatment options or alternatives; and

§  To offer you health-related benefits or services that you might be interested in.

§  To perform analyses (e.g. data analytics and aggregation), research, development, improvement and marketing of our programs generally.

We will not use your health information for fundraising or formal Research projects without your consent. If you consent to receive fundraising or research communications from us, you may cancel your consent at any time by notifying us in writing at compliance@monogramhealth.com or 1-855-212-2273 (TTY 711).  If you have questions concerning how we use your information, please contact Monogram Health’s Privacy Office at compliance@monogramhealth.com or 1-855-212-2273 (TTY 711).

Please note: Once your health information has been used or disclosed, the use or disclosure is permanent.  This means, information used or disclosed prior to your change or cancellation of authorization cannot be unused or undisclosed.

Other Uses or Disclosures of Your Health Information

In any other situation not covered by this Notice of Privacy Practices, we will ask for your written authorization before using or disclosing any other health information about you, including before using or disclosing psychotherapy notes.  If you choose to authorize the use or disclosure of health information about you, you may change or cancel your authorization at any time by notifying us in writing of your decision.

Please note: Once your health information has been used or disclosed, the use or disclosure is permanent.  This means, information used or disclosed prior to your change or cancellation of authorization cannot be unused or undisclosed.

Who Will Follow This Notice of Privacy Practices?

Monogram Health provides healthcare and other services to our clients and patients in partnership with other professionals and healthcare organization. This Notice of Privacy Practices will be followed by:

§  Any Monogram healthcare professional who provides health services to you at Monogram Kidney Care;

§  All departments and affiliated covered entities of Monogram Health; and

§  All employees, health staff, affiliates, and trainees of the entities listed above.

While each of these entities and affiliates operate independently, they may share your health information for coordination of care, treatment, payment, and healthcare operations.

Your Rights Regarding Your Health Information

You have the following rights regarding your health information:

§  Right to be Notified of a Breach: We will notify you in the event that the confidentiality of your information has been breached.

§  Right to Access Your Health Records: In most instances, you have the right to look at or get a copy of your health information that we create and maintain to make decisions about your care. All requests for copies or access to health records must be submitted in writing in advance. If you request for access to your health records is granted, we will work with you to pick a convenient time and place. If you request copies of your health records, we may charge a fee for the cost of copying, mailing or other related supplies. We may deny your request and/or ask you to contact your health plan instead. If we deny your request to review or obtain a copy, you may submit a written request to us for a review of that decision. 

§  Right to Amend Your Health Records: If you believe the information in your health record is incorrect or that important information is missing, you have the right to request that we correct the health record, by submitting a request in writing that provides your reason for requesting a change or amendment to the Monogram Health Privacy Office Address or Phone number listed below. We could deny a request to amend or change your health record if the information is not maintained by us or if we determine that the information in your health record is accurate. You may submit a written statement of disagreement to us with the decision by us to not amend your record to the Monogram Health Privacy Officer at compliance@monogramhealth.com.

§  Right to an Accounting: You have the right to ask for a list of any disclosures we have made of your health information. To request a list of disclosures, indicate the period of time you’d like us to provide you a list of disclosures we have made of your health information to the Monogram Health Privacy Office Address listed below. Please note: We can provide a list of disclosures for up to the past 6 years.  We do not keep any disclosures made prior to 6 years ago.

§  Right to Request Confidential Communications

You have the right to request that we communicate with you about your health information in the confidential manner requested by you. For example, you may request that we send mail to you at an address other than your home.  In order to request that we communicate with you in a specific way or at a specific location, please send us a request in writing to the Monogram Health Privacy Office at compliance@monogramhealth.com.

§  Right to Request A Paper Copy of this Notice of Privacy Practices:  You may request a paper copy of this Notice of Privacy Practices even if you have agreed to receive it electronically. Please ask your treating physician, your Monogram Health Program employees, personnel, staff members and contractors, or contact Monogram Health’s Privacy Office using the contact information below.

§  Right to Request Restrictions: You may request, in writing to the Monogram Health Privacy Office Address below, that we not use or disclose your health information for treatment, payment or healthcare operations or to persons involved in your care unless you specifically authorize it OR unless required by law or in an emergency. We will consider your request and try to accommodate it, but we are not legally required to restrict the use or disclosure of your data unless all of the following conditions are met:

§  You request that we NOT share your information with an insurer for purposes of payment or other purposes unrelated to your treatment;

§  You pay all charges associated with the services you receive out-of-pocket in full; and

§  We are NOT required by law to release your information to the insurer.

We will inform you of our decision in writing. All written requests or appeals should be submitted to compliance@monogramhealth.com.

 Changes to this Notice of Privacy Practices

We may change our privacy practices and policies at any time. Any changes will apply to health information we currently have, as well as to any new information we receive after the change occurs. Before we make any significant changes to our policies, we will change our Notice of Privacy Practices and post the new Notice of Privacy Practices in waiting areas, exam rooms, and on our website at www.monogramhealth.com. You can request a current copy of our Notice of Privacy Practices at any time. The effective date of the current Notice of Privacy Practices is listed on the bottom of each page of the Notice of Privacy Practices document. Paper copies of the current notice of Privacy Practices will be available to you each time you come into our facility for treatment.  You will be asked to acknowledge at least annually in writing that you have received this Notice of Privacy Practices.

Complaints

If you are concerned that your privacy rights may have been violated, or you disagree with any actions we have taken or decisions we have made with regards to your health information, you may contact Monogram Health Privacy Office at compliance@monogramhealth.com or 1-855-212-2273 (TTY 711). If you are not satisfied with our response, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Officer can provide you with that address upon request. Under no circumstances will we penalize or retaliate against you for filing a complaint.