Renovaré Functional Medicine, LLC
NOTICE OF PRIVACY PRACTICES
Effective Date: January 21, 2022
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.
Your health information is private, and no one without a legitimate need to know may have access to it. Renovaré Functional Medicine, LLC (“Practice”) is required by law to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. In the unlikely event that your health information becomes unsecured, Practice will provide you with prompt notification.
Practice will not use or disclose your health information except as described in this Notice of Privacy Practices (“Notice”). This Notice applies to all of the medical records generated during your treatment at Practice.
EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
The following categories describe the ways that Practice may use and disclose your health information:
Treatment: Practice will use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued treatment of the patient. For example, a healthcare provider treating you for an injury can ask another healthcare provider about your overall health condition.
Payment: Practice may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing and reimbursement. The information may be released to an insurance company, third-party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, to the extent Practice bills for services it provides to you, a bill sent to a third-party payor may include information that identifies you, your diagnosis, the procedures and supplies used.
Routine Healthcare Operations: Practice may use and disclose your medical information during routine health care operations to run our practice, improve your care, and contact you when necessary. For example, we can use your health information to manage your treatment and services.
Business Associates: Practice may use and disclose certain health information about you to its business associates. A business associate is an individual or entity under contract with Practice to perform or assist Practice in a function or activity that necessitates the use or disclosure of medical information. Examples of business associates include but are not limited to, a copy service used by the Clinic to copy medical records, consultants, independent contractors, accountants, lawyers, medical transcriptionists and third-party billing companies. Practice requires the business associate to protect the confidentiality of your medical information. In addition, Practice requires any subcontractor of Practice’s business associate to protect the confidentiality of your medical information.
Regulatory Agencies: Practice may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, billing practices may be audited by the State Auditor and records are subject to review by the Secretary of Health and Human Services and his/her authorized representatives.
Workers’ Compensation: Practice may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
Military Veterans: Practice may disclose your medical information as required by military command authorities if you are a member of the armed forces.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, Practice may release your medical information to the correctional institution or law enforcement official.
Organ and Tissue Donation Requests: Medical information can be shared with organ procurement organizations.
Medical Examiner or Funeral Director: Medical information can be shared with a coroner, medical examiner, or funeral director when an individual dies.
Required by Law: Practice will disclose medical information about you when required to do so by law, for example, responding to lawsuits and legal actions.
Other Uses: Any other uses and disclosures will be made only with your written authorization.
PATIENT INFORMATION RIGHTS
Although all records concerning your treatment obtained at Practice are the property of Practice, you have the following rights concerning your medical information:
Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request that Practice contact you only at work or by mail.
Right to Inspect and Copy: You have the right to inspect and copy your medical information.
Right to Amend: You have the right to amend your medical information. Any request for amendment should be submitted to Practice in writing, stating a reason in support of the amendment.
Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information. Practice is not required to honor your request except where: (i) the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid Practice in full.
Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice.
Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information.
Right to Choose Someone to Act For You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to Practice at 843 East 4th Street, Suite A, Ainsworth, NE 69210 or by contacting Practice at (402) 302-0090.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact our office at (402) 302-0090. If you believe your privacy rights have been violated, you may file a complaint with us by calling (402) 302-0090 and with the U.S. Department of Health and Human Services Office for Civil Rights by calling 1-800-368-1019, visiting https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, emailing [email protected], or sending a letter to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
We will not retaliate against you for filing a complaint.
CHANGES TO THIS NOTICE
Practice will abide by the terms of the Notice currently in effect. Practice reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. An updated version of the Notice may be obtained at Practice.
