Notice of Privacy Practices for a Healthcare Provider

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.

Notice of Privacy Practices

Organization: Coordinated Medical I PLLC (the “Company”)
Effective Date: October 1, 2024

This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information that the Company may make. It also describes your rights to access and control your protected health information and certain obligations we have regarding the use and disclosure of your protected health information.

Your “protected health information” is information about you created and/or received by us, including demographic information, which may reasonably identify you and that relates to your past, present, or future physical or mental health or condition, or payment for the provision of your health care.

The Company is required by law to maintain the privacy of your protected health information. The Company is also required by law to provide you with this Notice of the Company’s legal duties and privacy practices with respect to your protected health information, to notify all affected individuals following a breach of unsecured protected health information when required by law, and to abide by the terms of the Notice that is currently in effect. However, the Company may change the Notice at any time, and the revised Notice will apply to all of your protected health information maintained by the Company. The Company will provide you with the revised Notice at your next appointment. If you would like to receive a copy of any revised Notice, you should access our website at www.honestmedicalgroup.com/policies/privacy or contact the Company’s Privacy Officer.

How the Company may Use or Disclose your Protected Health Information

The Company will ask you to sign a consent form that allows the Company to use and disclose your protected health information for treatment, payment, and health care operations. You will also be asked to acknowledge receipt of this Notice.

The following categories describe some of the different ways that we may use or disclose your protected health information. Even if not specifically listed below, Company may use and disclose your protected health information as required by law or as authorized by you. The Company will make reasonable efforts to limit access to your protected health information to those persons or classes of persons, as appropriate, in the Company’s workforce who need access to perform their duties. In addition, as required by law, we will make reasonable efforts to limit the protected health information to the minimum amount necessary to accomplish the intended purpose of any use or disclosure.

  • For Treatment: Company may use and disclose your protected health information to provide you with medical treatment and related services. If the Company is permitted to do so, it may also disclose your protected health information to individuals or facilities that will be involved in your care after you leave Company and for other treatment continuation of care coverage reasons. The Company may also use or disclose your protected health information in an emergency situation.
  • For Payment: Company may use and disclose your protected health information so that it can bill and receive payment for the treatment and related services that you receive. For billing and payment purposes, the Company may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid, or another third-party payer. For example, the Company may need to give your health plan information about the treatment you received so your health plan will pay or reimburse the Company for the treatment. The Company may also contact your health plan to confirm your coverage or to request prior authorization for a proposed treatment.
  • For Healthcare Operations: Company may use and disclose your health information as necessary for the operations of the Company, such as quality assurance and improvement activities, reviewing the competence and qualifications of health care professionals, medical review, legal services and auditing functions, and general administrative activities.
  • Business Associate: There may be some services provided by Company’s business associates, such as a billing service, transcription company, or legal or accounting consultants. The Company may also disclose your protected health information to its business associate so that the business associate can perform the job it has been asked to do. To protect your health information, the Company requires all business associates to enter into a written contract that requires them to appropriately safeguard your information.
  • Appointment Reminders: Company may use and disclose protected health information to contact you as a reminder that you have an appointment with Company.
  • Treatment Alternatives and Other Health-Related Benefits and Services: Company may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives and to tell you about health-related benefits, services, or medical education classes that may be of interest to you.
  • Individuals Involved in Your Care or Payment of Your Care: Unless you object, the Company may disclose your protected health information to a family member, a relative, a close friend, or any other person you identify, if the information relates to the person’s involvement in your health care to notify the person of your location or general condition or payment related to your health care. In addition, the Company may disclose your protected health information to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure, the Company may disclose such information if it determines that it is in your best interest based on your provider’s professional judgment or if the provider reasonably infers that you would not object.
  • Public Health Activities: Company may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information, such as for the purpose of preventing or controlling disease; injury or disability; reporting births, deaths, or other vital statistics; reporting child abuse or neglect; notifying individuals of recalls of products they may be using; notifying a person who may have been exposed to s disease or may be at risk of contracting or spreading a disease or condition.
  • Health Oversight Activities: Company may disclose your protected information to a health oversight agency for activities aurhorized by law, such as audits, investigations, inspections, accreditation, licensure, and disciplinary actions.
  • Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, Company may disclose your protected health information in response to your authorization or a court or administrative order. The Company may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process if such disclosure is permitted by law.
  • Law Enforcement: Company may disclose your protected health information for certain law enforcement purposes if permitted or required by law. For example, to report gunshot wounds; to report emergencies or suspicious deaths; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
  • Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations: Company may release your protected health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization incolced in the donation of organs and tissues.
  • Research Purposes: Your protected health information may be used or disclosed for research purposes, but only if the use and disclosure of your information has been reviewed and approved by a special Privacy Board or Institutional Review Board, or if you provide authorization.
  • To Avert a Serious Threat to Health or Safety: Company may use and disclose your protected health information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.
  • Military and National Security: If required by law, if you are a member of the armed forces, Company may use and disclose your protected health information as required by military command authorities or the Department of Veterans Affairs. If required by law, the Company may disclose your protected health information to authorized federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities authorized by law. If required by law, the Company may disclose your protected health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations.
  • Worker’s Compensation: Company may use or disclose your protected health information as permitted by laws relating to worker’s compensation or related programs.
  • Special Rules Regarding Disclosure of Reproductive Health Information: Neither the Company nor its business associates may use or disclose protected health information potentially realted to reproductive health care for (A) judicial and/or administartive hearings, (B) law enforcement purposes, or (C) coroner or medical examiner purposes without first obtaining a valid attestation from the requesting individual and/or entity.
    • Mental health information.
    • Substance abuse treatment information. If you are treated in a specialized substance abuse program, the confidentiality of alcohol and drug abuse patient records is protected by Federal law and regulations. Generally, the Company may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser, unless:
      • You consent in writing;
      • The disclosure is allowed by court order; or
      • The disclosure is made to a medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. o Violation of these Federal laws by the Company is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any infromation about a crime committed by a patient either at the substance abuse program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
      • HIV-related information.
      • Minors.

When We May Not Use or Disclose Your Protected Health Information

Except as described in this Notice, or as permitted by State or Federal law, Company will not use or disclose your protected health information without your written authorization.

Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, Company may condition treatment on the provision of an authorization, such as for research related to treatment. If you do authorize us to use or disclose your protected health information for reasons other than treatment, payment or health care operations, you may revoke your authorization in writing at any time by contacting Company’s Privacy Officer. If you revoke your authorization, Company will no longer use or disclose your protected health information for the purposes covered by the authorization, except where the Company has already relied on the authorization.

Psychotherapy Notes

A signed authorization or court order is required for any use or disclosure of psychotherapy notes except to carry out certain treatment, payment, or health care operations and for use by Company for treatment, for training programs or for defense in a legal action.

Marketing

Marketing Activities: A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or services except for limited circumstances, such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by Company. An authorization is not required to describe a health-related product or service provided by use; to make communications to you regarding your treatment; or to direct or recommend alternative treatments, therapies, providers, or settings of care for you.

Sale of Protected Health Information

A signed authorization is required for the use or disclosure of your protected health information in the event that the Company directly or indirectly receives remuneration for such use or disclosure, except under certain circumstances as allowed by federal or state law. For example, authorization is not needed if the purpose of the use or disclosure is for your treatment, public health activities, or providing you with a copy of your protected health information.

Your Health Information Rights

You have the following rights with respect to your protected health information. The following briefly describes how you may exercise these rights.

  • Right to Request Restrictions of Your Protected Health Information: You have the right to request certain restrictions or limitations on the protected health information Company uses or discloses about you. You may request a restriction or revise a restriction on the use or disclosure of your protected health information by providing a written request stating the specific restriction requested. You can obtain a Request for Restriction form from the Company. The Company is not rquired to agree to your requested restriction, unless it involves the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations that pertains solely to a health care item or service for which the Company has been paid out of pocket in full by you or a third party (other than the health plan) on your behalf. If the Company does agree to accept your requested restriction, it will comply with your request except as needed to provide you with emergency treatment. If restricted protected health information is disclosed to a health care provider for emergency treatment, the Company will request that such health care provider not further use or disclose the information. In addition, you or the Company may terminate the restriction if the other party is notified in writing of the termination. Unless you agree, the termination of the restriction is only effective with respect to protected health information created or received after we have informed you of the termination.
  • Right to Receive Confidential Communications: You have the right to request a reasonable accommodation regarding how you receive communications of protected health information. Specifically, you have the right to request an alternative means of communication or an alternative location where you would like to receive communications by submitting a request in writing on a Request for Confidential Communications form to the Company’s Privacy Officer. You can obtain a Request for Confidential Communications form from the Privacy Officer.
  • Right to Access, Inspect, and Copy Your Protected Health Information: You have the right to access, inspect, and obtain a copy of your protected health information that is used to make decisions about your care for as long as the protected health information is maintained by the Company. If the Company maintains your information electronically in a designated record set, then you have the right to request an electronic copy of such information. To access, inspect, and/or copy your protected health information, you must submit your request in writing to the Company. If you request a copy of your protected helath information, we may charge a fee for the costs of preparing, copying, mailing, and/or other costs associated with your request. Within thirty (30) days of your request, the Company will respond to your request in writing either to, (A) in whole or in part, grant or deny your request to access, inspect, and/or copy your protected health information, or (B) explain the reasons why the Company cannot yet respond to your request, incuding the date by which the Company will respond. The Company will respond to your request for access no later than sixty (60) days from the date the Company received your request. If the Company denies your request, it will provide you with a written reponse including (1) an explanation of the reason for the denial, (2) information regarding whether the denial may be reviewed, and (3) contact information for the designated individual to whom you may submit a complaint related to your request. In certain circumstances, you have the right to have the Company’s denial reviewed by a licensedhealth care professional (designated by the Company) to act as a reviewing official. This individual will not have participated in the original decision to deny your request.
  • Right to Amend Your Protected Health Information: You have the right to request an amendment to your protected health informaion for as long as the informaion is maintained by the Company. Your request must be made in writing on a Request for Amendment Form and must state the reason for the requested amendment. You can obtain a Request for Amendment form from the Company. Within sixty (60) days of receipt of your request, Company with respond in writing either to (A) in whole or in part, grant or deny your request to amend your protected health information, or (B) explain the reasons why the Company cannot yet respond to your request, including the date by which it will respond. The Company will respond to your request for amendment no later than ninety (90) days after it receives your completed Request for Amendment form. If the Company accepts your request for amendment, Company will make the amendment, provide you with notice of the same, and make reasonable efforts to inform and provide the amendment within a reasonable time to persons you identified as having received your protected health information needing amendment. If the Company denies your request for amendment, it will give you a written statement including (A) the reasons for the denial, (B) explaining your right to submit a written statement disagreeing with the denial, (C) if you decide to forego submission of a written statement disagreeing with the denial, your right to request that Company include your request for amendment and Company’s denial of same with any future disclosures of your protected health information subject to amendment, and (D) contact information for the designated individual to whom you may submit a complaint related to your request. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.
  • Right to Receive an Accounting of Disclosures of Protected Health Information: You have the right to receive an accounting of certain disclosures of your protected health information by the Company over the six (6) years preceding the date of your request. To request an accounting of disclosures, you must submit a request in writing, stating a time period that falls within the six (6) years preceding the date of your request. You may request an accounting of disclosures of your personal heath information once per year, without charge. For each additional request of accounting submitted in the same calendar year, the Company may charge you a reasonable, cost-based fee. Within sixty (60) days of receipt of your request for an accoutning, the Company will respond to your request in writing to either (A) provide the requested accounting, or (B) explain the reasons why the Company cannot yet respond to your request, including the date by which it will respond. The Company will respond no later than ninety (90) days after it receives your written request for accounting.
  • Right to Obtain a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting the Company’s Privacy Officer, whose contact information is included below. In addition, you may obtain an electronic copy of this Notice for printing at www.honestmedicalgroup.com/policies/privacy.
  • Right to Complain: You may file a complaint with the Company or the Secreatary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with the Company by notifying the Privacy Officer of your complaint. You will not be penalized for filing a complaint and the Company will make every reasonable effort to resolve your complaint with you.

It is important to read and understand this Notice of Privacy Practices before signing any Acknowledgement of Receipt of the Notice of Privacy Practices.

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact the Company’s designated Privacy Officer:

Mail: Coordinated Care I PLLC c/o Honest Medical Group LLC
ATTN: Privacy Officer
210 Athens Way, Ste. 100
Nashville, TN 37228

Email: PrivacyOfficer@honestmedicalgroup.com

Phone: (313) 586-0267