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.
If you have questions about this notice or want more information, please
contact: our Privacy Officer at (800) 930-5956. The
effective date of this notice is May 1, 2023.
To appropriately treat you and receive payment for the services we provide, we
need to obtain information from you. While we are not a “covered entity” and
are not subject to federal requirements under the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA”), we limit our use and disclosure of
your information consistent with Massachusetts and New Hampshire law.
We will use and disclose this information and other information we collect in
the ways described below.
To help you understand how we will use and
disclose your information we have put the different uses and disclosures into
categories and give examples of each. All of the ways we use or disclose your
information will fit into one of the categories listed below, but we cannot
list all of the uses and discloses in each category.
We may use and disclose your health information for treatment, payment, and
health care operations.
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Treatment. We may use and disclose your information to
provide you with medical treatment and services. Your information may be
disclosed to individuals and facilities providing care to you. These
individuals and facilities need your information to provide care, and to
coordinate and provide services (such as prescriptions, lab tests, meals,
and x-rays).
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Payment. We may use and disclose your information to
receive payment for the services and treatment provided to you. We use your
information to create a bill and disclose your information when we send the
bill to your insurance company, you, or a third party. The individual or
entity paying the bill may request more information to determine whether the
bill is covered by your insurance. We may tell your health plan about a
treatment you are going to receive to get approval for payment or to
determine whether your health plan will cover the treatment.
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Health Care Operations. We may use and disclose your
information for health care operation purposes. Health care operations
includes review of the care you receive for quality assessment, educational,
business planning, and compliance plan purposes.
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Appointment Reminders. We may provide appointment reminders
to you. You may request in writing that we send reminders to a confidential
or alternative address.
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Treatment Alternatives. We may provide you with information
about treatment alternatives and other health related benefits and services.
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Waiting Rooms. We may use a sign-in-sheet at the
registration desk where you will be asked to sign your name. We may also
call you by name in the waiting room when we are ready to begin your
treatment.
We may also disclose your health information to outside entities without your
consent or authorization in the following circumstances:
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Required by Law. We disclose information as required by
law. For example, we are required to report gunshot wounds to the police.
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Public Health Purposes. We disclose information to health
agencies as required by law for preventing or controlling disease. Examples
are reporting of sexually transmitted, communicable, and infectious
diseases.
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To Prevent a Serious Threat to Health or Safety. We may
disclose information about you to law enforcement or an identified victim to
prevent a serious threat to your health or safety or the health or safety of
another individual or the public.
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Research. Your information may be used by or disclosed to
researchers for research approved by a privacy board or an institutional
review board.
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Health Oversight Activities. Your health information may be
disclosed to governmental agencies and boards for investigations, audits,
licensing, and compliance purposes.
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Judicial and Administrative Proceedings. We may be required
to disclose your health information to a court or for an administrative
proceeding.
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Law Enforcement Activities. We may be required to disclose
your information as required by law, pursuant to a court order, warrant,
subpoena, or summons.
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Deceased Individual. We may disclose information for the
identification of the body or to determine the cause of death.
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Military and Veterans. If you are a member of the armed
forces we may release information about you as required by military command
authorities. We may also release information about foreign military
personnel to the appropriate foreign military authority.
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Inmates. If you are an inmate of a correctional institution
or under the custody of a law enforcement official. This release must be
necessary (1) for the institution to provide you with health care; (2) to
protect your health and safety or the health and safety of others; or (3)
for the safety or security of the correctional institution.
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Organ and Tissue Donation. If you are an organ donor, we
may release your medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ bank, as
necessary to facilitate organ or tissue donation.
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Workers’ Compensation. We may release medical information
about you for workers’ compensation or similar programs.
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Specialized Governmental Functions. We may release
information about you to authorized Federal officials for intelligence,
counterintelligence, and other national security activities authorized by
law.
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Business Associates. We sometimes work with outside
individuals and businesses that help us operate our business successfully.
We may disclose your health information to these business associates that
that they can perform these tasks we hire them to do. Our business
associates must provide us with certain written assurances that they will
respect the confidentiality of your personal and identifiable health
information.
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Individuals Involved in Care. We may tell your friends,
relatives and other caretakers information
which is relevant to their
involvement in your care.
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Disaster Relief. We may disclose information about you to
public or private agencies for disaster relief
purposes.Except as
provided above, we will obtain your written authorization prior to
disclosure of your information for any other purpose. Specifically, written
authorization is required prior to the disclosure of your information:
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Psychotherapy Notes. We will not use or disclose your
psychotherapy notes without a written authorization except as specifically
permitted by law.
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Marketing. We will not use or disclose your information for
marketing purposes, other than face-to-face communications with you or
promotional gifts of nominal value, without your written authorization.
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Sale of Information. We will not sell your PHI without your
written authorization, including notification of the payment we will
receive. Where a disclosure is made under your written authorization, you
have the right to revoke the authorization at any time. Revocation of an
authorization must be in writing. The revocation is effective as of the date
you provide it to Northeast Men's Health and does not affect any prior disclosures made
under the authorization.
Your Rights
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You have the right to request a restriction on how information about you is
used and disclosed.
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You have the right to request communications with you be made at an
alternative address or phone number.
- You have the right to inspect and copy your medical record.
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If you believe the information we have about you is incorrect or incomplete
you may request that we amend your medical record.
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You have the right to request a list of individuals and entities that
received your health information for reasons other than treatment, payment,
or healthcare operations.
- You have the right to request a paper copy of this Notice.
Our Duties
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We are required by law to maintain the privacy of your information and to
provide you with this Notice of our legal duties and privacy practice
regarding health information.
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We are required to notify you if there is a breach of your unsecured
information.
- We are required to follow the terms of the current Notice.
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We may change the terms of this Notice and the revised Notice will apply to
all health information in our possession. If we revise this Notice, a copy
of the revised Notice will be posted and a copy may be requested from our
Privacy Officer at the number listed at the beginning of this form.
Questions and Complaints
If you have any questions regarding our privacy practices, desire to request
an action related to your rights, or believe your privacy rights have been
violated, please contact our Privacy Officer:
Jeff Dillon
CEO
1780 South Bellaire Street, Suite 355
Denver,
CO 80222
(720) 372-1501
Jeff.dillon@promeniq.com
