Notice of Privacy Practices

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

WHO WILL FOLLOW THIS NOTICE?

This Notice describes the practices of Connect Health + Wellness (CHW) and the practices that will be followed by all CHW professionals and employees who handle your health information.

OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION

CHW understands that health information about you and your health is personal. We are committed to protecting health information about you. We maintain our records and conduct our treatment environment with the goal of providing the highest level of protection for your health information and care. This Notice applies to all the records of your care, which are received or created by CHW.

Your other health treatment providers (e.g., doctors, nurse practitioners, psychiatrists, psychologists, hospitals, and all other providers) may have different policies or notices regarding the use and disclosure of your health information.

This notice will tell you generally about the ways in which CHW may use and disclose health information about you but does not include all specific examples of uses and disclosures of health information. If you have any questions about uses and disclosures of your health information, you may contact the privacy official of CHW designated below. Your health information, also referred to as protected health information, is that information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health information and related health care services. In this Notice, we also describe your rights and certain obligations CHW has regarding the use and disclosure of protected health information.

We are required by law to:· 

• Make sure that health and other information that identifies you (protected health information) is kept private.
• Give you this Notice of our legal duties and privacy practices with respect to protected health information about you that explains how, when, and why we may use or disclose protected health information; and
• Comply with the Notice that is currently in effect.

USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

By becoming a client of CHW, you are giving consent for CHW to use your protected health information for certain activities, including treatment, payment, and other health care operations.

1. Treatment: CHW, we may use and disclose protected health information about you so that its professionals and employees can treat you. For example, we may obtain information from other providers about you so that we can be fully aware of your health history. We may also provide protected health information about you to other providers who may assist us with, or consult with us about, your treatment. For example, we may need to disclose information to a case manager who is responsible for coordinating your care. We may also disclose your health information to our clinicians and staff who are directly involved in your care. We may also share protected health information among members of your interdisciplinary treatment team, including treatment team members that are representatives of governmental agencies, representatives of other providers involved in your treatment, and other team members, representatives or advocates on the treatment team who are not health care professionals.

2. Payment: CHW may also use and disclose protected health information about you so that we may be paid for the health treatment we provide you. For example, we may provide information about your health treatment to your health insurance company, whether government or private, including but not limited to Medicaid, Medicare, or other payors or administrative service organizations, so that we can receive payment for the treatment we have provide you or to comply with the policies of the health insurance company or other payor. These uses and disclosures include determinations of eligibility, reviews as to medical necessity of services, reviews as to whether services are authorized or certified, and utilization reviews to determine appropriateness of services.

3. Health care operations: CHW may also use and disclose protected health information about you for health care operations, in other words, those other tasks that we need to perform to deliver quality health services to you. For example, we may use information about your health treatment to evaluate the quality of health care rendered to you by our professionals and staff. We may use or disclose your protected health information for purposes of obtaining and maintaining any licensure, certification, accreditation, and qualifications, for conducting utilization review and for responding to audits.

4. Specific uses and disclosures: The following uses and disclosures of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses, and disclosures made by CHW are only those which are permitted under the law)

USES AND DISCLOSURES FOR APPOINTMENT REMINDERS: CHW may use and disclose your protected health information to contact you or leave a message for you as a reminder that you have an appointment at the office. However, we will do so consistently with your directions as to who we may contact and the way the contact will be made regarding such reminders. You must advise us in writing as to your specific directions regarding disclosure of protected health information concerning reminders, and any changes to such directions. We will accommodate all reasonable requests.

USES AND DISCLOSURES TO OTHERS INVOLVED IN YOUR HEALTH CARE: CHW will honor your

directions as to contacts with your family, a relative, a close friend, or any other person you identify, regarding your protected health information. You must advise us in writing as to your specific directions regarding disclosure of protected health information about your care, and any changes to your directions. We will not disclose any information related to your protected health information to others unless you specifically authorize us to disclose this information in writing. We will not disclose any genetic information for underwriting purposes. We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

USES AND DISCLOSURES OF ALCOHOL AND OTHER DRUG RECORDS: The law provides that we may use/disclose your protected health information from alcohol and other drug records without consent or authorization in the following circumstances. We may disclose Protected Health Information when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to a court order. We may also disclose protected health information relating to an individual’s death if state or federal law requires the information for collection of vital statistics or injury into cause of death. In certain circumstances, we may disclose protected health information for research, audit, or evaluation purposes. To avoid a serious threat to health or safety, we may disclose protected health information to law enforcement when a threat is made to commit a crime on the program premises or against program personnel.

USES AND DISCLOSURES RELATED TO MINORS: Health records for minors will normally be released to custodial parents or parents that are otherwise authorized to obtain access to this information, legal guardians, and other legal representatives. There are certain circumstances in which disclosure of the health records of minors to parents is prohibited by law, such as certain records related to prenatal care and birth control, alcohol and substance abuse services, treatment of venereal disease, and other exceptions recognized by law. CHW will abide by these prohibitions when we are required to do so. If CHW determines that a minor is sufficiently mature to independently make decisions regarding health care, CHW may also require the authorization of such a mature minor to release such records.

USES AND DISCLOSURES IN EMERGENCY SITUATIONS: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will attempt to obtain your acknowledgment of this notice as soon as reasonably practicable after the delivery of treatment.

USES AND DISCLOSURES FOR HEALTH-RELATED BENEFITS OR SERVICES: From time to time,

CHW may use and disclose protected health information to tell you about certain health-related benefits or services that may be of interest to you.

USES AND DISCLOSURES REQUIRING AUTHORIZATION: As required by law, psychotherapy notes, marketing and fundraising efforts, and the sale of protected health information require your authorization before your health information is released. Any other uses and disclosures that are not described in the Notice of Privacy Practices will only be made with your written authorization. You may also revoke your authorization at any time.

USES AND DISCLOSURES RELATED TO FUNDRAISING/MARKETING ACTIVITIES:

CHW will not use or disclose your protected health information in fundraising activities unless you authorize CHW in writing to do so. CHW may use or disclose general information about your health care services that does not include personally identifiable information about you in its fundraising efforts without further authorization from you. If you do not want to receive communications regarding fundraising efforts, you have a right to clearly and conspicuously opt-out of some or all communications.

USES AND DISCLOSURES REQUIRED BY LAW: CHW will use or disclose protected health information about you when required to do so by federal, state, or local law, including reports of suspected abuse, neglect, domestic violence, and/or criminal activity. We may also use or disclose protected health information when required to do so by a court order. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if the law requires us to do so, of any such uses or disclosures. We must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the law.

USES AND DISCLOSURES FOR PUBLIC HEALTH ACTIVITIES: CHW may disclose your protected health information for public health activities and disclosure for such purposes will be to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury, or disability. Disclosures to public health authorities may include disclosure to a foreign authority that is working with the public health authority.

USES AND DISCLOSURES RELATED TO COMMUNICABLE DISEASES: CHW may disclose your

protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Disclosure of AIDs-related testing information and related health records is limited to specific involuntary circumstances without specific AIDS-related records consent. All information regarding such a test will remain confidential, except for specific exceptions in which the law allows or requires uses or disclosures, unless authorized by you.

DISCLOSURES FOR HEALTH OVERSIGHT ACTIVITIES: CHW may disclose protected health information to protection and advocacy groups, quality control and utilization review committees, governmental agencies, and health oversight agencies for activities authorized by law. These activities include, but not limited to, reviews, audits, investigations, and inspections. These activities are necessary to monitor the health care system, the delivery of health care, government benefit programs, other government regulatory programs, civil rights laws, and compliance with applicable federal and state laws.

DISCLOSURES OF ABUSE OR NEGLECT: CHW may disclose your protected health information to a public health authority authorized by law to receive reports of abuse or neglect to children or to adults. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to a governmental entity or agency authorized to receive such information. In such cases, the disclosure will only be made in accordance with Virginia law.

DISCLOSURES TO THE FOOD AND DRUG ADMINISTRATION: CHW may disclose your protected health information to a person or company required by the Food and Drug Administration (FDA) to report adverse events, product defects or other problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements; or to conduct post-market surveillance, as required.

DISCLOSURES FOR LAWSUITS AND DISPUTES, TO AVERT THREATS TO HEALTH AND SAFETYOR TO LAW ENFORCEMENT: CHW may disclose protected health information about you in response to a court order or administrative order. We may be required to disclose protected health information about you in response to a subpoena, discovery request, or other lawful process. CHW may disclose your protected health information, consistent with federal and Virginia laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public, or if it is necessary for law enforcement authorities to identify or apprehend an individual. We may also release protected health information if asked to do so by a law enforcement official, as required by federal and state law, in response to a court order, subpoena, warrant, summons, or similar process. We will first make reasonable efforts to tell you about the request at the most recent address you have provided to CHW so that you can take any actions you feel are appropriate to protect your interests. In addition, if we are prohibited by law from disclosing protected health information regarding mental health records, alcohol and substance abuse records and/or AIDS related records without first obtaining your written authorization or a court order as required by federal and state laws, we will take reasonable steps to comply with these restrictions and will disclose this information only if you authorize us or we are compelled by law to do so.

Other related disclosures may include disclosures relating to individuals who are Armed Forces personnel, to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the President of the United States or other authorized persons or foreign heads of state.

DISCLOSURES TO CORONERS, FUNERAL DIRECTORS, AND FOR ORGAN DONATION

CHW may disclose protected health information about you to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties required by law. We may also disclose protected health information about you to a funeral director to permit the funeral director to carry out legal duties and may do so if death is reasonably anticipated. Your protected health information may also be disclosed for certain organ donations to which you may have agreed.

DISCLOSURES FOR RESEARCH: CHW may disclose your protected health information to researchers when their research has been approved and protocols have been established to ensure the privacy of your information. We may also disclose a limited portion of your information, as allowed under the law, for research purposes.

DISCLOSURES FOR WORKERS’ COMPENSATION: CHW may release protected health information about you for workers’ compensation, social security disability, federal black lung and similar programs. These programs provide benefits for work-related injuries or illness.

IF YOU DO NOT AGREE WITH ANY OF THE USES OF PROTECTED HEALTH INFORMATION, YOU MUST REQUEST A SPECIFIC LIMITATION ON THE ABOVE USES IN WRITING TO OUR OFFICE.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.

Right to Request, Inspect, and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your health care. Usually this right includes both health and billing records. You must submit your request in writing and the format must be readily producible. Your request must also include the date and your signature and must clearly identify the designated recipient and where to send the copy of the protected health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. Your request to inspect and copy your information may be denied under certain circumstances and you have a right to request that any such denial be reviewed. All requests will be addressed within 30 days, or an extension may be attached, in accordance with the law.

Right to Request Restrictions: You have the right to request that we restrict the use and disclosure of your protected health information for treatment, payment, and health care operations. You also have the right to restrict certain disclosures of your protected health information for the purposes of carrying out payment or health care operations, particularly when you pay out of pocket for items or services and if it the disclosure is not otherwise required by law. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment unless there is an exception requiring such use or disclosure. To request restrictions, you must make your request in writing to the Compliance Official of CHW. In your request, you must tell us: (1) What information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Confidential Communications: The patient has the right to request to receive private health information communications (such as test results, appointment reminders, etc.) by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Compliance Official of CHW. We will not ask you a specific reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Amend: If you feel that the protected health information, we have about you is incorrect or incomplete, you have the right to request that your protected health information be amended. Only the health care entity (e.g., health center) that created your protected health information is responsible for amending it. For more information regarding the procedures for submitting such a request, contact the Compliance Official of CHW listed below.

Right to an Accounting of Disclosures: You have a right to an accounting of disclosures of your protected health information, for purposes other than treatment, payment, or health care operations by CHW or any of the people or companies who perform treatment, payment, or health care operations on our behalf. To request this list of disclosures we made of protected health information about you, you must submit a request in writing to the Compliance Official of CHW. Your request must state a period, which may not be longer than six (6) years prior to the date of your request and may not include dates before April 16, 2003. Your request should indicate the form in which you want the list (for example, on paper or electronically). CHW may charge a reasonable fee to you for providing this information to you according to its current policies.

Right to be Notified in the Event of Improper Disclosure: You have a right to and will receive notifications of any breach of your unsecured protected health information.

Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Privacy Official of CHW at the address or telephone number specified below.

CHANGES TO THIS NOTICE: CHW reserves the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for protected health information we already have about you, as well as any information we create or receive in the future. The notice will contain, in the bottom, left-hand corner, the effective date. If we do so, we will post a new notice at all clinic sites on the effective date, and you may request a copy at the registration desk at any clinic site. In addition, you may obtain a copy from the privacy official designated below.

OTHER USES OF PROTECTED HEALTH INFORMATION: This notice describes the limited rights of CHW to use and disclose your protected health information. Other uses and disclosures of your protected health information not covered by this notice or the laws that apply to CHW will be made only with your written permission ("authorization"). If we disclose protected health information to an outside entity, we will take reasonable steps to assure the outside entity protects the confidentiality of your protected health information, including, if necessary, agreements with the outside entity intended to protect your privacy. If you provide us with permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the health treatment or other services that we have provided to you for a limited period.

COMPLAINTS AND INQUIRIES: If the patient believes his or her privacy rights have been violated and/or that CHW has not followed this policy, you may file a complaint with CHW Compliance Officers or with the Secretary of the Department of Health and Human Services in Washington, D.C. To file a complaint with CHW contact the Compliance Officer of CHW at the address and telephone number listed below.

You will not be penalized for filing a complaint. If you have questions about this Notice or about filing a complaint, you may contact the Compliance Officer designated below.

PRIVACY OFFICIAL OF CHW  

Dewey Knight, Compliance Officer

Telephone number (276) 403-5098

Gina Finocchiaro, Compliance Office

Telephone number: (276) 403-5096
 

EFFECTIVE DATE: 05/24/2022

Updated: 07/2013; 07/2016; 04/2019; 02/24/2020; 05/24/2022, 10/4/2022; 3/10/2024

PATIENT ACKNOWLEDGMENT FORM: Our Notice of Privacy Practices (Notice) provides information about how we may use and disclose protected health information about you. The patient has the right to receive and review our Notice before signing this acknowledgment. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy.