HIPAA Notice of Privacy Practices
Effective Date: September 1, 2018
This notice outlines your protected health information, how it may be used, and what your rights are as a client. Please review carefully and ask any questions prior to signing. Questions about this notice can be directed to Empirical Wellness LLC.
Shaun Stearns, PhD
Empirical Wellness LLC
6855 S Dayton
Greenwood Village, Colorado 80112
Phone: (720) 696-0450
Our Pledge Regarding Protected Health Information:
We, Empirical Wellness LLC, understand that your health information is personal. We are committed to protecting your health information. This Notice applies to all records generated by Empirical Wellness LLC, made by Empirical Wellness LLC. This Notice indicates the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations regarding the use and disclosure of protected health information.
The law requires us to make sure that personally identifiable health information is kept private, notify you about how we protect your health information, explain how, when and why we use and disclose protected health information, and follow the terms of the Notice that is currently in effect.
We are required to follow the procedures in this Notice and reserve the right to change the terms of this Notice and make new provisions effective for your collected health information:
- posting the revised Notice on our website
- making copies of the revised Notice available upon request
How We May Use And Disclose Protected Health Information About You
The following categories describe how we use and disclose protected health information without your written authorization:
We may use your protected health information to coordinate or manage your medical treatment or services. We may disclose your protected health information to doctors, nurses, technicians, medical students, or other personnel who are involved in your medical care. We may use and disclose your protected health information to contact you as a reminder that you have an appointment with Empirical Wellness LLC. We may use and disclose your protected health information to tell you about or recommend possible treatment options, alternatives, health-related benefits or services.
For Payment for Services:
We may use and disclose your protected health information so that the treatment and services you receive at Empirical Wellness LLC may be billed to and payment may be collected from you.
We may disclose your protected health information to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and is necessary to prevent or lessen a serious and imminent threat to you or another person.
For Health Care Operations:
We may use and disclose your protected health information for Empirical Wellness LLC health care operations, such as our quality assessment and improvement activities, case management, business planning, customer services and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care.
We may also combine protected health information Empirical Wellness LLC patients to decide what additional services Empirical Wellness LLC should offer, what services to remove, and new treatments are effective.
As Required By Law:
We will disclose your protected health information when required to do so by federal, state or local law.
Judicial and Administrative Proceedings:
If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or obtain an order protecting the information requested.
Health Oversight Activities:
We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to safeguard your information.
To Avert a Serious Threat to Health or Safety:
We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Coroners, Medical Examiners, and Funeral Directors:
We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
We may disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.
YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:
We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death.
If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.
Your Rights Regarding Protected Health Information About You
You have the following rights regarding protected health information we maintain about you:
Right to Inspect and Copy:
You have 24 hour access to your health information through a private page that only yourself and Empirical Wellness LLC has access to.
Right to Amend:
If you feel that your protected health information is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing or email submitted to Empirical Wellness LLC. In addition, you must provide a reason that supports your request. We will act on the/ your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you.
In addition, we may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment, is not part of the protected health information kept by Empirical Wellness LLC, is not part of the information which you would be permitted to inspect and copy, or we believe is accurate and complete.
Right to an Accounting of Disclosures:
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing or email to Empirical Wellness LLC. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following:
- For your treatment
- For billing and collection of payment for your treatment
- For health care operations
- Made to or request by you, or that you authorized
- Occurring as a byproduct of permitted use and disclosures
- For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates
- As part of a limited data set of information that does not contain information identifying you
Right to Request Restrictions:
You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing or email to Empirical Wellness LLC.
Right to Request Confidential Communications:
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. To request confidential communications, you must make your request in writing to Empirical Wellness LLC. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice:
You have the right to a paper copy of this Notice at any time by contacting Empirical Wellness LLC.
Other Uses and Disclosures
We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.
You May File A Complaint About Our Privacy Practices
If you believe your privacy rights have been violated, you may file a complaint with Empirical Wellness LLC, or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way.