This document provides a simplified explanation of how Meridian Wellness DBA Avenue Health (“Avenue Health”) protects your health information, how we may use and share it, your rights under HIPAA, and an authorization allowing us to help you with claims and benefit issues.
Avenue Health is committed to safeguarding your Protected Health Information (PHI), which includes any information that identifies you and relates to your health, diagnoses, treatment, medications, insurance, or services you receive. We may use and disclose your PHI for your treatment, to coordinate care, to process billing and insurance claims, and for healthcare operations such as quality improvement and staff training. We may also share PHI when required by law, including reporting public health concerns, responding to court orders or law enforcement requests, and preventing serious threats to your safety or the safety of others.
You have important rights regarding your PHI. You may request access or receive a copy of your medical record, ask for corrections if information is inaccurate, request limits on how your information is used or shared, and ask that we communicate with you by a preferred phone number, address, or method. You may also request a list of certain disclosures we have made of your information and may ask for a paper or electronic copy of this Notice at any time. We will not use or disclose your PHI for purposes not described in this Notice, such as marketing unrelated to treatment or releasing psychotherapy notes, unless you give written permission.
Avenue Health must protect your PHI, follow federal privacy laws, notify you if a breach occurs involving your information, and share only the minimum necessary information needed for a specific purpose. We work with trusted business partners, such as billing companies, laboratories, and IT vendors, who are also required to safeguard your information through Business Associate Agreements.
By signing the authorization portion of this document, you authorize Avenue Health, its affiliates, employees, and agents to use and disclose your protected health information including information related to diagnosis, treatment, claims, payment, and healthcare services, along with your name, address, Social Security number, and member ID number for the purpose of assisting you with resolving claims and health benefit coverage issues. You understand that information disclosed to another person or organization may be subject to re-disclosure and may no longer be protected by federal or state privacy laws.
You understand that you have the right to revoke this authorization at any time by submitting a written notice to Avenue Health. However, your revocation will not apply to actions already taken based on your previous authorization. You also understand that you are entitled to receive a copy of this authorization. You further acknowledge that this authorization is voluntary, and your decision not to sign will not affect your eligibility for benefits, enrollment, payment for services, or coverage.
By signing, you acknowledge that you have been informed of Avenue Health’s Privacy Practices, Release of Billing Information Policy, Assignment of Benefits Policy, and you grant Avenue Health Medication Authorization Authority. If you are a legal representative signing on behalf of a patient, you confirm that you have the legal authority to do so and will provide proof such as a Power of Attorney, living will, or guardianship documentation.
If you believe your privacy rights have been violated, you may file a complaint with Avenue Health’s Privacy Officer or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.