This Notice describes how health information about you may be used and how you can get access to this information.
Please review this Notice carefully.
This Notice of Privacy Practices (Notice) applies to all covered entities under HIPAA affiliated with Urgent Team Management, LLC.*
OUR DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION
We understand that health information about you is personal, and we are committed to protecting this information. This Notice applies to all of your protected health information maintained by us, including records relating to your care at an Urgent Team Center and/or healthcare records received by us from another source. We are required by HIPAA to:
- Maintain the privacy of your PHI;
- Provide you with this Notice as to our legal duties and practices with respect to PHI;
- Notify you following a breach of unsecured PHI; and
- Follow the terms of the Notice currently in effect.
OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION
The following categories describe different ways we may use and disclose your PHI:
- For Treatment. We may use or disclose your PHI for treatment, such as to physicians, nurses, nurse practitioners, physicians assistants, technicians, or other healthcare providers who are involved in taking care of you.
- For Payment. We may use or disclose your PHI to seek or receive payment for services that you receive, including payment from an insurance company or government payor.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
As permitted by HIPAA, we may use or disclose your PHI from our records (even after your death) without your permission in the following circumstances.
- As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law. For example, we must comply with laws regarding reports of abuse or neglect or domestic violence. We may also share health information to help with product recalls or to report adverse reactions to medications.
- Health Oversight Activities. We may disclose PHI about you for health oversight activities. These activities may include audits, investigations, inspections, and licensure. These activities are necessary for the state and federal government to monitor the healthcare delivery system.
- Individuals Involved in Your Care. We may release PHI to the person you named in your advance directive and to persons involved in your care or the payment for your care that you’ve selected and notified us may receive your PHI.
- Public Health. We may disclose PHI about you for public health activities. These activities may include the reporting of certain diseases, injuries, and disabilities.
- Research. In certain circumstances, and under supervision of a facility’s institutional review board or a privacy board, we may disclose PHI in order to assist medical research.
- To Avert a Serious Threat to Health or Safety. We may use or disclose your PHI when necessary to prevent or lessen a serious threat to you or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
- Decedents. We may use or disclose a deceased patient’s PHI as authorized by federal or state law, including based on the signed authorization of the estate’s representative.
- Lawsuits and Administrative Disputes. We may disclose your PHI in response to a court order, administrative order, or in response to a valid subpoena or discovery request.
- Marketing. We may use or disclose PHI as permitted under HIPAA for certain marketing purposes, but only if we obtain a valid written authorization from you.
- Business Associates. We may use or disclose PHI to our Business Associates as allowed by HIPAA. Business Associates have written agreements with us which contain specific assurances to protect your health information.
- Personal Representatives. We may use or disclose PHI to persons who are authorized by law to make health care decisions for you.
- Affiliates. We may disclose your PHI to our affiliates in connection with your treatment, payment for our services, or other affiliate related activities.
- Other Uses and Disclosures. Other uses and disclosures not described in this Notice will be made only with your written authorization. For example, most uses of psychotherapy notes require an authorization. You have the right to revoke any authorization you have signed.
- Fundraising. We may use your PHI for Urgent Team’s fundraising purposes. You have the right to opt out of receiving such communications.
- Appointment Reminders/Other Information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- For Specific Government Functions. As permitted by HIPAA, we may disclose PHI to law enforcement, to government benefit programs relating to eligibility and enrollment, and for workers’ compensation, disaster relief, military, and the interest of national security/protective services.
- Respond To Organ and Tissue Donation Requests. We may share health information about you with organ procurement organizations.
- Work With Medical Examiner or Funeral Director. We may share health information with a coroner, medical examiner, or funeral director when an individual dies.
- Workers’ Compensation. We can use or share health information about you for workers’ compensation claims.
- Note: We will comply with applicable state laws that protect certain types of PHI such as substance abuse, mental health, genetics, and HIV/AIDS and we will not share this type of health information except as permitted by such laws, which may require your written permission.
Your Privacy Rights
You have the following rights regarding health information we maintain about you:
- Right to Inspect and Request a Copy. In most cases, you have the right to look at or get an electronic or paper copy of your medical record. You must make the request in writing. You may be charged a reasonable fee for the cost of copying your records.
- Right to Amend. If you feel that there is a mistake or missing information in our record of your PHI, you may ask us to correct or add to the record. Your request must be made in writing, and you must provide a reason that supports your request. We may deny your request under certain circumstances and we will tell you why in writing within 60 days. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response you provide, appended to your PHI. You may also have a right to review your denial.
- Right to Know What Health Information We Have Released. You have the right to ask for a list (“an accounting”) of those with whom we’ve shared information. You must request this list in writing and state the period of time this list should cover for a period of no longer than six (6) years. The first list you receive within a twelve (12) month period will be free.
- Right to Request Restrictions. You have the right to ask us to limit how your PHI is used and disclosed. You must make the request in writing and tell us what information you want to limit and to whom the limits apply. For example, you could request that we not disclose to your spouse a blood test you received. We are not required to agree with your request. If we agree, however, we will comply with your request unless the information is needed to provide you with emergency treatment or the information can be disclosed without your authorization.
- Right to Restrict Disclosure to Health Plan. You have the right to restrict disclosure of PHI to a health plan if the disclosure is for purposes of payment or healthcare operations, is not required by law, and the PHI pertains only to a healthcare item or service for which we have been paid in full out of pocket. We are required to agree to this request unless a law requires us to share that information.
- Right to Confidential Communications. You have the right to ask that we communicate with you in a certain way or at a certain place. For example, you may ask us to send information to your work address instead of your home address. You must make your request in writing. You will not have to explain the reason for your request. We will honor all reasonable requests.
- Right to Receive Written Notice. Affected individuals have the right to receive written notice following a breach of their unsecured PHI.
- Right to Receive a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time. To get a copy of this Notice:
- Print a copy from our website www.urgentteam.com;
- Ask one of our Team Members who can print a copy from our internal website; or
- Send a request to our Privacy Officer.
- We reserve the right to change our privacy practices and this Notice at any time and to make such changes effective to all PHI that we maintain. A Notice will be available on request and on our website as indicated above.
- Choose Someone to Act for You. If you have given someone a durable power of attorney for healthcare or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has the authority and can act for you before we take any action.
* This Notice applies to all HIPAA covered entities affiliated with Urgent Team Management, LLC.
- Urgent Team of Arkansas Physicians, LLC
- Urgent Team of Georgia Physicians, LLC
- Crossroads Urgent Care, PLLC
- Convenient Care Clinic, LLC
- Golden Triangle Urgent Care, LLC
- Burton Hills Primary Care, PLLC
- Advantage Family Care, Inc.
These separate legal entities are or may be part of an Affiliated Covered Entity (ACE) which is treated under HIPAA as one covered entity. As permitted by HIPAA, we may use one Notice of Privacy Practices and may disclose information about you within the ACE, including for treatment, payment and other purposes. References to ACE and affiliates are for HIPAA purposes only and will be periodically updated.
** Effective Date of this Notice is 01/01/15.
HOW TO GET MORE INFORMATION OR SUBMIT A COMPLAINT
If you have any questions about this Notice or would like further information, please contact Urgent Team’s PRIVACY OFFICER listed below. If you believe we have violated your privacy rights, you may file a written complaint with Urgent Team and/or the Office of Civil Rights. Both are listed below. You will not be denied care or retaliated against for filing a complaint.
ATTN: Colleen Shanahan
30 Burton Hills Blvd., Suite 175
Nashville, TN 37215
Office of Civil Rights
U.S. Department of Health & Human Services
200 Independence Ave., SW
Room 509F, HHH Building Washington, DC 20201