Notice of Privacy Practice

Personal Health Information (PHI) and HIPAA Statement

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.

What is Personal Health Information (PHI)?

PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present, or future physical or mental health or condition, (b) the provision of health care to you, or (c) your past, present, or future payment for the provision of health care. As you use this tele-health service, your Provider, with the assistance of Qvidity (“Provider”), will receive and create records containing your PHI. Provider is required by law to maintain the privacy of your PHI and to provide you with notice of its legal duties and privacy practices with respect to your PHI.

Agreement to Terms of Privacy Policy

In order to use Provider’s services, it will need to collect and store your PHI. Provider takes your privacy seriously. By using Provider, you agree to allow it to use your PHI as described in this Privacy Policy. In using Provider’s tele-health services, you agree to read this Privacy Policy. Provider’s tele-health services are not intended for use by minors under the age of eighteen (18). If a minor user would like to use these services to learn information, the user’s parent or guardian must agree to this Privacy Policy personally and on behalf of the minor.

Provider must abide by the terms of this Policy while it is in effect. This current Policy takes effect on June 1, 2017, and will remain in effect until Provider replaces it. Provider reserves the right to change the terms of this Policy at any time, as long as the changes are in compliance with applicable laws. If Provider changes the terms of this Policy, the new terms will apply to all PHI that it maintains, including PHI that was created or received before such changes were made. If Provider changes this Policy, it will post the new Policy on its Web site and will make the new Policy available upon request.

Use of your PHI by Provider

In providing the tele-health services discussed in this Policy, Provider may use your PHI in any of the following ways:

  • Answer your questions
  • Treat you
  • Bill for your services
  • Help with public health and safety issues
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation
  • Law enforcement, and other government requests
  • Respond to lawsuits and legal actions
  • Public health activities

By using the tele-health services outlined in this Policy, you authorize us to use and disclose your PHI in these circumstances. The following are examples of situations in which you authorize us to use or disclose your PHI:

  • Provider may disclose your PHI to another physician or health care provider for purposes of a consult or in connection with the provision of follow-up treatment.
  • Provider may use and disclose your PHI to your health insurer or health plan in connection with the processing and payment of claims and other charges.
  • Provider may use and disclose your PHI in connection with its health care operations, such as providing customer services and conducting quality review assessments.
  • Provider may engage third parties to provide various services for Provider. If any such third party must have access to your PHI in order to perform its services, Provider will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Policy.
  • Provider may use and disclose your PHI to the extent required by law.
  • Provider may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, and reporting to the Food and Drug Administration regarding the quality, safety, and effectiveness of a regulated product or activity.

Your Rights Regarding Your PHI

When it comes to your PHI, you have certain rights. This section explains your rights and some of the responsibilities of Provider to help you.

Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other PHI Provider has about you. Ask how to do this. Provider will provide a copy or a summary of your PHI, usually within 30 days of your request. Provider may charge a reasonable, cost-based fee.

Ask Provider to correct your medical record
You can ask to correct PHI about you that you think is incorrect or incomplete. Ask how to do this. Provider may refuse your request, but you will be provided with a written explanation for the refusal within 60 days.

Request confidential communications
You can ask Provider to contact you in a specific way (for example, home or office phone) or to send mail to a different address. Provider will honor all reasonable requests.

Ask Provider to limit what it uses or shares
You can ask Provider not to use or share certain PHI for treatment, payment, or its operations. Provider is not required to agree to your request, and may refuse if it would affect your care. If you pay for a service or healthcare item out-of-pocket in full, you can ask Provider not to share that information for the purpose of payment or its operations with your health insurer. Provider will honor such a request unless a law requires that information to be shared.

Get a list of those with whom Provider has shared your PHI
You can ask for a list (accounting) of the times Provider has shared your PHI for six years prior to the date of your request, with whom your PHI was shared, and the reason it was shared on each occasion. Provider will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked to be made). Provider will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another accounting within 12 months.

Get a copy of this Privacy Policy
You can ask for a paper copy of this Privacy Policy at any time, even if you have agreed to receive the notice electronically. Provider will provide you with a paper copy promptly.

Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. Provider will make sure the person has this authority and can act for you before it takes any action.

File a complaint if you feel your rights are violated
You can complain if you feel Provider has violated your rights by contacting it using the information below. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. Provider will not retaliate against you for filing such a complaint.

Responsibilities of Provider with Your PHIM

  • Provider is required by law to maintain the privacy and security of your PHI.
  • Provider will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • Provider must follow the duties and privacy practices described in this Privacy Policy and give you a copy of it.
  • Provider will not use or share your PHI other than as described here unless you provide authorization in writing. If you provide such written authorization, you may change your mind at any time. You must provide written notice if you change your mind.

Further Inquiries or Notices

If you would like additional information or have questions about this Privacy Policy, the privacy contact is Storm Clinic, who is available by phone at 605.271.5441. To discuss a complaint under this Privacy Policy or regarding the use of your PHI, please contact Provider at 605.271.5441.