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.
Effective Date: February 24, 2022
This Notice of Privacy Practices ("Notice") applies to Zoe Therapy Services, LLC and ZoeStyle Medicine, LLC, which are Affiliated Covered Entities under HIPAA. This means that Zoe Therapy Services, LLC and ZoeStyle Medicine, LLC are under common ownership and control and are designated as a single Covered Entity for purposes of complying with the HIPAA Privacy Rule.
This section describes your rights regarding the health information we maintain about you. All requests or communications to us to exercise your rights discussed below must be submitted in writing to firstname.lastname@example.org.
- 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 health information we have about you. We will provide you with access to or a copy of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee as authorized by law.
- Ask us to correct your medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. We may say "no" to your request, but we'll tell you why in writing within 60 days.
- Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests. We will not ask you the reason for your request.
- Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, unless the request is regarding disclosure of health information to your health insurer and (i) you pay for a service or health care item out-of-pocket in full, and (ii) the disclosure is for the purpose of payment or our operations with your health insurer.
- Get a list of those with whom we've shared information: You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
- Get a copy of this Notice: You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly. A paper copy is always available at www.zoerva.com
- File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting Path CCM, Inc., Attn: Privacy Officer, 4470 W Sunset Blvd Suite 107 PMB 94731, Los Angeles, CA 90027 or by contacting our Privacy Officer by telephone at 323-205-7088 or by email at email@example.com at zoerva.com.
- You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.
- We will not retaliate against you for filing a complaint.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
We typically use or share your health information in the following ways.
Treat you: We can use your health information and share it with other professionals who are treating you. Examples: We may contact you to remind you of your scheduled appointments or a missed appointment. Or a provider treating you for anxiety asks a primary care doctor about your overall health condition.
Run our organization: We can use and share your health information to run our practice, improve your care and contact you when necessary. We may disclose your health information to third-party business associates and qualified service organizations who perform services on our behalf. Examples: We use health information about you to manage your treatment and services. We may contact you for satisfaction surveys.
Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
USES AND DISCLOSURES WITHOUT YOUR PERMISSION
We are allowed or required to share your information in other ways including:
Public health and safety issues: We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence.
Do research: We can use or share your information for health research under certain circumstances.
Comply with the law: We will share your health information as required by state or federal laws.
Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests: We can share health information about you: For workers' compensation claims, For certain law enforcement purposes, with law enforcement officials, or for other purposes as required by law such as reporting certain types of injuries, With health oversight agencies for activities authorized by law like audits and investigations, For special government functions such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.
To avert a serious threat to health or safety: If there is a serious threat to the health and safety of you or another person, we may use and disclose your health information to someone able to help lessen the threat.
Family and Friends: If you verbally agree to the use or disclosure and in certain other situations, we may disclose limited health information to your family or friends involved in your care or who helps pay for your care. We may also use or disclose your health information to disaster- relief organizations so that your family or other persons responsible for your care can be notified about your condition, status, and location.
Fundraising: We may contact you for fundraising purposes, but you can tell us not to contact you again. We will care for you regardless of your participation in fundraising.
ADDITIONAL USES AND DISCLOSURES
We may not use or disclose your health information for any purposes not above unless you give us your written authorization. For example, we do not use or disclose your psychotherapy notes, use or disclose your health information for marketing purposes, or sell your health information except with your authorization or as otherwise permitted by law.
If you change your mind after authorizing a use or disclosure of your health information, you may withdraw your permission by revoking the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization. To revoke an authorization, you must notify our Privacy Officer in writing.
Please be aware that State and other Federal laws may have additional requirements that we must follow or may be more restrictive than HIPAA on how we use and disclose certain of your health information. If there are specific more restrictive requirements, even for some of the purposes listed above in this Notice, we may not disclose your health information without your written permission as required by such laws.
CONFIDENTIALITY OF SUBSTANCE USE DISORDER RECORDS
Federal law and regulations, under 42 USC § 290dd-2 and 42 CFR Part 2 (collectively, "Part 2"), protect the confidentiality of substance use disorder patient records maintained by the Group. We may not release that information protected by Part 2 unless:
- You consent in writing;
- The disclosure is allowed by a court order meeting the requirements of Part 2; or
- The disclosure is: made to medical personnel in a medical emergency; for research purposes; to a qualified service organization; for audit or program evaluation purposes.
Additionally, we do not need written authorization to:
- Communicate internally
- Report crimes committed on the premises, or against program personnel
- Report suspected child or elder maltreatment, abuse or neglect or exploitation.
- Disclose information relating to cause of death or vital statistics
- Disclose information to the FDA so it can notify patients or physicians of product dangers
We will not disclose your presence in treatment to individuals who may contact the Group unless you have provided your written authorization permitting the release. To the extent applicable state law is more restrictive than Part 2 on how we use and disclose your health information, we comply with more restrictive law. Violation of the Federal law and regulations related to substance use disorder patient records is a crime and violations may be reported to the United States Attorney for jurisdiction where services are received as well as to the Substance Abuse and Mental Health Services Administration office responsible for opioid treatment program oversight.
- We are required by law to maintain the privacy and security of your health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this Notice and give you a copy of this Notice.
CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this Notice, and the changes will apply to all information we currently have about you as well as any information we receive in the future. The new notice will be available upon request and on our website. The Notice will always contain an effective date.
If you have questions or concerns about your privacy rights, or the information contained in this Notice, please contact Zoe's Privacy Officer by mail at Zoe Therapy Services, Attn: Privacy Officer, 4191 Innslake Dr, Suite 211, Glen Allen, VA 23060, by telephone at 804-303-9622 or by email at firstname.lastname@example.org.
Zoe Therapy Services