A. PRIVACY IS OUR PRIORITY
Revive Low T Clinic is committed to keeping your individually identifiable health information (IIHI) private. In conducting our business, we will create records regarding you and your treatment and the services we provide to you. As required by law, we will maintain the confidentiality of your health information.
A federal regulation, known as the HIPAA Privacy Rule, requires that we provide detailed notice in writing of our privacy practices. We realize that these laws are complicated, but we must provide you with the following important information:
Your rights to privacy in IIHI
How we may use and disclose your IIHI
Our obligations concerning IIHI disclosure and use
The terms of this notice apply to all records with your IIHI. We may 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 clinic has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our current Privacy Practices Notice is posted in the clinic. If you wish to receive a copy please advise our staff.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Privacy Officer: Barry wheeler
VIA ONE OF THE FOLLOWING METHODS:
Mail: Revive Low T Clinic, 11911 NE 132nd St, Suite 103, Kirkland, WA 98034
Phone: (206) 960-4770
Email: drbarry@revivelowt.com
C. WE MAY USE AND DISCLOSURE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Our clinic staff – including, but not limited to, our doctors and medical assistants, or a referred provider – may use or release your IIHI in order to treat you, or to assist others in your treatment. Additionally, we may need to disclose your IIHI to others who may assist in your care, such as your spouse, children, or parents.
2. Payment. Our clinic may use and disclose your IIHI in order to bill and collect payment for the services and medications you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment and health status to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members or insurance companies. Also, we may use your IIHI to bill you directly for services and items.
3. Health Care Operations. Our clinic may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our clinic may use your IIHI to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for our clinic.
4. Appointment Reminders. Our clinic may use and disclose your IIHI to contact you or a family member who answers the phone (or to leave a recorded message) to remind you of an upcoming appointment.
5. Treatment Options. Our clinic may use and disclose your IIHI to inform you of potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our clinic may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our clinic may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to our office for care. In this example, the babysitter may have access to this child’s medical information.
8. Disclosures Required by Law. Our clinic will use and disclose your IIHI when we are required to do so by federal, state, or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
We may use or disclose your identifiable health information as required by law or with your permission in the following circumstances:
1. Public Health Risks. Our clinic may disclose your IIHI to public health authorities that are authorized by law to
collect information for the purpose of:
Maintaining vital records, such as births and deaths
Reporting child abuse or neglect
Preventing or controlling disease, injury or disability
Notifying a person regarding potential exposure to a communicable disease
Notifying a person regarding a potential risk for spreading or contracting a disease or condition
Reporting reactions to drugs or problems with products or devices
Notifying individuals if a product or device they may be using has been recalled
Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
Notifying your employer under limited circumstances related primarily to workplace injury or illness or
medical surveillance
2. Health Oversight Activities. Our clinic may disclose your IIHI 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 clinic may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. In general, we will require that the party that requests your records provide a records-release form, signed by you within the last 3 months.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
Concerning a death we believe has resulted from criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identify/locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identify or location of the perpetrator)
5. Deceased Patients. Our clinic may release IIHI 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. Organs and Tissue Donation. Our clinic may release your IIHI 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.
8. Serious Threats to Health or Safety. Our clinic may use and disclose your IIHI 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.
12. Workers’ Compensation. Our clinic may release your IIHI for worker’s compensation and similar programs.
Your Rights Regarding Protected Health Information About You
Under federal law, you have these rights regarding PHI about you:
Right to Request Restrictions: You have the right to request additional restrictions on the PHI that we may use or disclose for treatment, payment and healthcare operations. You may also request additional restrictions on our disclosure of PHI to certain individuals involved in your care that otherwise are permitted by the Privacy Rule. We are not required to agree to your request. If we do agree to your request, we are required to comply with our agreement except in certain cases, including where the information is needed to treat you in the case of an emergency. To request restrictions, you must make your request in writing to our Privacy Official. In your request, please include (1) the information that you want to restrict; (2) how you want to restrict the information (for example, restricting use to this office, only restricting disclosure to persons outside this office, or restricting both); and (3) to whom you want those restrictions to apply.
Right to Receive Confidential Communications: When patients request services from us, we routinely obtain their consent to receive certain communications from us by email. However, you have the right to request that you receive communications regarding PHI in a certain manner or at a certain location. For example, you may request that we contact you by regular mail rather than email. You must make your request in writing. You must specify how you would like to be contacted (for example, by regular mail to your post office box and not your home). We are required to accommodate only reasonable requests.
Right to Inspect and Copy: You have the right to request the opportunity to inspect and receive a copy of PHI about you in certain records that we maintain. This includes your medical and billing records but does not include psychotherapy notes or information gathered or prepared for a civil, criminal or administrative proceeding. We may deny your request to inspect and copy PHI only in limited circumstances. To inspect and copy PHI, please contact our Privacy Officer. If you request a copy of PHI about you, we may charge you a reasonable fee for the copying, postage, labor and supplies used in meeting your request.
Right to Amend: You have the right to request that we amend PHI about you as long as such information is kept by or for our office. To make this type of request, you must submit your request in writing to our Privacy Officer. You must also give us a reason for your request. We may deny your request in certain cases, including if it is not in writing or if you do not give us a reason for the request.
Right to Receive an Accounting of Disclosures: You have the right to request a list of certain disclosures that we have made of PHI about you. This is a list of disclosures made by us during a specified period of up to six years, other than disclosures made for treatment, payment and healthcare operations; for use in or related to a facility directory; to family members or friends involved in your care; to you directly; pursuant to an authorization of you or your personal representative; for certain notification purposes (including national security, intelligence, correctional and law enforcement purposes); as incidental disclosures that occur as a result of otherwise permitted disclosures; as part of a limited data set of information that does not directly identify you; and before January 14, 2010. To make a request, please contact our Privacy Officer using the contact information listed below. The first list that you request in a 12-month period will be free, but we may charge you for our reasonable costs of providing additional lists in the same 12-month period. We will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred.
Right to a Paper Copy of this Notice: You have a right to receive a paper copy of this Notice at any time, even if you have previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact our Privacy Officer using the contact information provided below.
The right to file a complaint with the US Department of Health & Human Services (HHS) and Revive Low T Clinic.
Please see our contact info below to make any of the requests described above.
Internet Privacy Policy
Thank you for visiting our web site. These privacy and posting policies tell you how we use personal information collected at this site and what information you may post and in what matter. Please read these policies before using the site or submitting any personal information on the blog, sign-up form, or posting any comments. By using the site, you are accepting the practices described in these privacy and posting policies. These practices may be changed, but any changes will be posted and changes will only apply to activities and information on a going forward, not retroactive basis. You are encouraged to review these policies whenever you visit the site to make sure that you understand how any personal information you provide will be used.
Note: the privacy practices set forth in this privacy policy are for this web site only. If you link to other web sites, please review the privacy policies posted at those sites.
Opt-Out Policy
You have the option to NOT receive emails from us at any time. If you can’t find the “opt-out” link at the bottom of any email from us just respond with ‘unsubscribe’ in the subject line and we will discontinue sending you emails.
Advanced Collection of Information
We collect personally identifiable information, like names, postal addresses, email addresses, etc., when voluntarily submitted by our visitors. The information you provide is used to fulfill your specific request. This information is only used to fulfill your specific request, unless you give us permission to use it in another manner, for example to add you to one of our mailing lists.
Cookie/Tracking Technology
The Site may use cookie and tracking technology depending on the features offered. Cookie and tracking technology are useful for gathering information such as browser type and operating system, tracking the number of visitors to the Site, and understanding how visitors use the Site. Cookies can also help customize the Site for visitors. Personal information cannot be collected via cookies and other tracking technology, however, if you previously provided personally identifiable information, cookies may be tied to such information. Aggregate cookie and tracking information may be shared with third parties.
Distribution of Information
We may share information with governmental agencies or other companies assisting us in fraud prevention or investigation. We may do so when: (1) permitted or required by law; or, (2) trying to protect against or prevent actual or potential fraud or unauthorized transactions; or, (3) investigating fraud which has already taken place. The information is not provided to these companies for marketing purposes.
Commitment to Data Security
Your personally identifiable information is kept secure unless you post it to our website as comment that may be publicly viewable. Only authorized employees, agents and contractors (who have agreed to keep information secure and confidential) have access to this information. All subscription based emails and newsletters from this site allow you to opt out of further mailings.
Additional Rights You May Have Regarding Your Data
Applicable laws may give you additional rights to request access to, or to request the erasure, correction or transfer of, your data. For example, the European Union’s General Data Protection Regulation (EU GDPR) provides certain rights to persons who were/are residing in the European Union when data were/are collected. If the EU GDPR applies to your data then you may ask to see your data or request, to the extent allowed by law, to have your data corrected or erased. You may also object to or request restrictions on how your data will be processed. You may ask that your data be forwarded or transferred to another organization. Finally, to the extent allowed by law, you may withdraw consent you have given to certain data processing, without penalty. If you do decide to withdraw consent at a later date, your withdrawal will not affect the legality of the processing of your data up to that point.
Privacy Contact Information
If you have any questions, concerns, or comments about our privacy policy you may contact us using the information below:
Privacy Officer: Barry Wheeler
By e-mail: drbarry@revivelowt.com
By Phone: (206) 960-4770 (USA)
We reserve the right to make changes to this policy. Any changes to this policy will be posted.
Washington Residents: Know your rights under the Balance Billing Protection Act