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MediPlant Funding
NOTICE OF PRIVACY PRACTICES
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.
MediPlant Funding
provides you with medical devices, equipment,
and/or supplies (the “MediPlant Funding Devices”).
MediPlant Funding receives and maintains your personal health information in
the course of providing the MediPlant Funding Devices and related services to you.
THIS NOTICE GIVES YOU
INFORMATION REQUIRED BY LAW about the duties
and privacy practices of MediPlant Funding
with regard to your protected health information.
MediPlant Funding is required
by law to protect the privacy of your personal health information.
THE EFFECTIVE DATE OF THIS
NOTICE IS October 1, 2009.
MediPlant
Funding
is required to follow the terms of this Notice until the Notice is
replaced. MediPlant Funding reserves the right to change the terms of this Notice at
any time. If MediPlant Funding makes changes to this Notice, MediPlant
Funding will revise it and
post the revised Notice on our website.
A revised Notice will be posted on our website, ____________, and
mailed to you upon your request. MediPlant
Funding
reserves the right to make the new changes apply to all your personal
health information maintained by MediPlant Funding after the date of the new Notice.
1.
Purposes for which MediPlant Funding may use or disclose
your personal health information.
MediPlant
Funding may use
or disclose your personal health information for the following purposes.
Applicable law generally requires MediPlant Funding to obtain your consent
before disclosing information for treatment, payment and operations
purposes, and may require your consent before disclosing for certain
other purposes described below.
MediPlant Funding does not need to obtain your consent to make a disclosure
that it is required by law.
For example, where MediPlant Funding is required by law to allow certain government
agencies to audit its records, MediPlant Funding may make this disclosure even without
your consent. Also, where
permitted by law, MediPlant Funding does not need to obtain your consent to make
certain other disclosures listed below, such as:
(i) a disclosure to comply with certain legal proceedings such as
a court order; (ii) a disclosure to avert a serious threat to your
health or safety or the health or safety of others; (iii) a disclosure
to various governmental authorities, such as health oversight agencies
or public health authorities, or law enforcement officials, or (iv) any
of the other disclosures set forth under the heading “for other reasons”
[NOTE:
Because we did not do a comprehensive analysis of NY law, we
cannot provide a definitive statement about which of these other
disclosures are permitted by law without consent in your case.
We drafted the general consent form to be broad and encompass all
of the following types of disclosures, though technically some may not
require consent. If a
person revokes their consent and you are subsequently requested by a
third party to make a disclosure, you will need to determine whether you
can do so at that point. If
you wish to or are requested to disclosing any of the “highly sensitive”
categories of information other than for the typical payment or
treatment related disclosures, we recommend that you consult counsel
prior to doing so as additional special requirements may apply that are
not reflected here. For
instance, alcohol/substance abuse information and HIV information cannot
be disclosed pursuant to a mere subpoena; a court order must be
provided.]. As part of
its standard operating procedure, prior to providing any services to
you, MediPlant Funding requests your consent to make disclosures for most of the
following purposes.
·
Treatment Purposes.
For example, MediPlant Funding may disclose your personal
health information to your doctor, at the doctor's request.
·
Payment.
For example, MediPlant Funding may use or disclose your
personal health information to obtain pre-authorization of the MediPlant
Funding
Devices and related medical procedure from your health or workers’
compensation insurer, to be paid for claims for covered health care
services, or to otherwise recover costs from other medical, workers
compensation or other insurance
or probate estates.
·
Health Care
Operations.
For example, MediPlant Funding or its contractors may use
or disclose your personal health information (1) to conduct quality
assessment and improvement activities; (2) to manage, plan, or develop
MediPlant Funding services and budget; and (3) to cooperate with state and federal
auditors.
·
Business Associates.
MediPlant
Funding may
disclose your personal health information to its business associates
that need access to your personal health information in order to provide
services or perform functions to or on behalf of MediPlant Funding.
An example of a business associate would be an independent
contractor or agent hired by MediPlant Funding to perform billing services for
MediPlant Funding.
MediPlant Funding has written contracts with its business associates designed
to protect the privacy of your personal health information.
·
As Required by Law.
For example, MediPlant Funding is required by law to allow
the United States Department of Health and Human Services to audit
MediPlant Funding
records. MediPlant Funding may also disclose
your personal health information necessary to comply with workers'
compensation or other laws. MediPlant Funding may also be required to disclose
personal health information about abuse, neglect, or domestic violence
to governmental or social services agencies.
·
For other reasons:
o
To comply with legal
proceedings, such as a court or administrative order or where permitted,
a subpoena;
o
To law enforcement
officials or to correctional institutions for limited law enforcement
and health and safety purposes;
o
To a family member,
friend or other person, to help you with your health care;
o
To your personal
representative appointed by you or designated by law;
o
To a health
oversight agency for activities authorized by law (these activities
include, for example, audits, investigations, inspections and licenses);
o
To a coroner,
medical examiner, or funeral director to identify a deceased person;
o
To an organ
procurement organization in limited circumstances;
o
To avert a serious
threat to your health or safety or the health or safety of others;
o
To federal officials
for lawful national security purposes or to conduct special
investigations and provide protection to the President, other authorized
persons and foreign heads of state;
o
To authorized public
health authorities for public health purposes;
o
To appropriate
military authorities, if you are a member of the armed forces;
o
For workers
compensation and similar programs that provide benefits for work-related
injuries and illnesses.
[NOTE:
We do not include a statement that MediPlant Funding can use PHI to contact the
individual re: treatment
alternatives, other health related information that might be of
interest, as we understand MediPlant Funding does not intend to do this]
You may revoke your consent at any time except to the
extent that action has already been taken in reliance on that consent.
Also, please note that, to the extent a disclosure is required by
law or permitted to be made without your consent, MediPlant Funding will still have
the right to make disclosures of your health information even after you
revoke your consent.
3.
More stringent protections for Sensitive Personal Health
Information.
“Sensitive
Health Information” means information relating to mental health, alcohol
or substance abuse, HIV/AIDS related information and test
results, and genetic test results.
Special legal protections apply to these types of information.
As a result, MediPlant Funding is generally required by applicable law to
obtain your written permission before disclosing your Sensitive Health
Information, unless the disclosure is required by law, or expressly
permitted by law.
To
comply with various legal requirements, MediPlant Funding uses a separate permission
form that is different from the “general consent” referenced above, to
obtain your permission to disclose Sensitive Health Information.
MediPlant Funding’s use and disclosure of Sensitive Health Information will be
subject to any special protections provided by applicable law.
3.
Uses and disclosures with your written authorization.
MediPlant Funding will not use or disclose your personal
health information, including any Sensitive Health Information, for any
other purposes unless you give MediPlant Funding your written authorization to do so.
In most cases, you may revoke your written authorization (or any
other consent or written permission mentioned in this Notice)
at any time.
Your revocation will be effective from the date MediPlant Funding receives the
revocation forward, for all your personal health information that
MediPlant Funding
maintains.
4.
Your rights
You may make a written request to MediPlant
Funding to do
one or more of the following concerning your personal health information
that MediPlant Funding maintains:
·
To put additional
restrictions on MediPlant Funding's use and disclosure of your personal health
information. MediPlant
Funding does not
have to agree to your request.
·
To have MediPlant
Funding
communicate with you in confidence about your personal health
information by a different means or at a different location than
MediPlant Funding is
currently doing. Your request must be in writing specifying the
alternative means or location to communicate with you.
·
To see and get
copies of your personal health information.
You may be charged a nominal fee for
the copies.
·
To request that we
amend your health information. MediPlant Funding may deny your request.
·
The right to receive
an accounting of disclosures as provided by law.
·
To have MediPlant
Funding send you
a paper copy of this Notice upon request.
If you want to exercise any of these rights described
in this Notice, please contact the MediPlant Funding Privacy Officer at the address
below.
5.
Complaints
If you believe your privacy rights have been violated
by MediPlant Funding, you have the right to complain to MediPlant
Funding or to the Secretary of the
U.S. Department of Health and Human Services.
You may file a complaint with MediPlant Funding at the address below.
MediPlant Funding will not retaliate against you if you choose to
file a complaint with either MediPlant Funding or with the U.S. Department of Health
and Human Services.
6.
Privacy Officer
To request additional copies of this Notice or to
receive more information about MediPlant Funding's privacy practices, your rights or
to file a complaint, please contact the Privacy Officer at the following
address:
Privacy Officer: 815-261-9403
60 B West Terra Cotta Ave., #260
Crystal Lake, IL 60014
