White Tree Medical
This notice, effective April 3 2017, describes how White Tree Medical may use and disclose your “Protected Health Information” (PHI) in compliance with the Health Insurance Portability and Accountability Act 1996 (HIPAA).
White Tree Medical is required to maintain the privacy of your PHI and to provide you with a notice about our legal duties and privacy practices with respect to your PHI. We are also required to accommodate reasonable requests you make to communicate PHI by alternative means or at alternative locations. Any time we use or disclose your PHI, we must follow the terms of this notice.
Uses and Disclosures of Your Protected Health Information Permitted by Law
According to the law, we may use or disclose your PHI to and/or for the following purposes:
(1) Treatment. To provide treatment to you or offer you various services. For example we may contact you to provide appointment reminders, offer health information tips, or to provide you with other health-related information.
(2) Payment. To obtain payment for services that we provide to you. This may include such activities as verifying your coverage, coordinating your benefits from a second payer, or processing an insurance claim and obtaining payment.
(3) Operations. For clinic operations, which may include administration and planning programs that improve the quality and effectiveness of the care that we provide you. Such programs may include business-planning activities, assessing and maintaining services, and conducting clinical quality assessment and improvement activities.
(4) Business Associates. There are some services we provide through contracts with our business associates. In such situations, we may disclose your personal health information to our business associates so they can perform the job we asked them to do. We require all business associates to appropriately safeguard your information, in accordance with applicable law.
(5) Individuals Involved in Your Care or Payment for Your Care. To a family member, a close personal friend or any other person identified by you if we (a) obtain your agreement, (b) provide you with the opportunity to object to the disclosure and you do not object; or (c) reasonably infer that you do not object to the disclosure.
(6) Healthcare Communications. To identify health-related services and products that may be beneficial to you, and then contact you about those services and products.
(7) Public Health Activities. To report the following to public health authorities, government authorities, or other services authorized by law to receive such reports: (a) health information for the purpose of preventing or controlling disease, injury or disability; (b) child, adult or elder abuse or neglect; (c) domestic violence; and (d) information about products under the jurisdiction of the US Food and Drug Administration.
(8) Health Oversight Activities. To a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs, such as Medicare or Medicaid.
(9) Judicial and Administrative Proceedings. In the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
(10) Threat to Health and Safety. To reduce or prevent a serious threat to public health and safety.
(11) Law Enforcement Officials; Specialized Government Functions. To the police or other law enforcement officials as required by law or in compliance with a court order; to military authorities for the personal and health information of armed forces personnel under certain circumstances; or to authorized federal officials for personal and health information required for lawful intelligence, counterintelligence or other national security issues.
(12) Workers’ Compensation. To comply with workers’ compensation laws.
(13) Substance Abuse Information
Alcohol and drug abuse information has special privacy protections. White Tree Medical will not disclose any information identifying an individual as being a substance abuse patient or provide any medical information relating to the patient’s substance abuse treatment unless (i) the patient consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits, or program evaluation; or (v) it is necessary to report a crime of a threat to commit a crime, or to report abuse or neglect as required by law.
Uses and Disclosures With Your Authorization
White Tree Medical cannot use your PHI for anything other than the reasons mentioned above without your signed authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
Your Individual Rights
(1) Right to Receive a Paper Copy of This Notice. Upon request, you may obtain a paper copy of this notice, even if you agreed to receive such notice electronically. White Tree Medical will post this notice prominently throughout our clinics and at www.whitetreemedical.com.
(2) Right to Access Your PHI. You may request access to your medical record file, as well as claims, claims payment, claims adjudication, medical management records, and your billing records maintained by us in order to inspect and request copies of these records. Under limited circumstances, we may deny you access to a portion of your records. If your request is denied, you will receive a written response. If you request a copy or copies of your record, you may be charged a fee.
(3) Right to Amend Your PHI. You have the right to request an amendment to your PHI. We will comply with your request unless we believe that the information you are requesting be amended is accurate and complete or other special circumstances apply. In such cases we are not required to grant your request.
(4) Right to Receive Confidential Communications. We will grant any reasonable request to receive confidential communications of PHI by alternative means or at alternative locations such as by mail to an address other than your home.
(5) Right to Request Additional Restrictions. You have the right to request in writing that we place additional restrictions on how we use or disclose your PHI. While we will consider any request for additional restrictions, we are not required to agree to your request. Additionally, you have the right to “opt out” with respect to receiving fundraising communications from us.
(6) Right to Receive An Accounting of Disclosures. You have the right to make a written request to receive an accounting of certain disclosures of PHI made by us or by our business associates.
(7) Right to Restrict Disclosure to Your Health Plan. You have the right to request in writing that we restrict the disclosure of certain personal health information to a health plan if the disclosure is for payment or health care operations and pertains to a healthcare item or service for which you have paid out of pocket in full. We will accommodate your request, except where we are required by law to make a disclosure.
(8) Right to Be Notified if Your Unsecured PHI is intentionally or unintentionally disclosed. You have the right to be notified following a breach of your PHI.
(9) Right to File a Complaint. If you believe your privacy rights have been violated, in addition to filing a complaint with us, you have the right to file a written complaint with the Office for Civil Rights of the United States Department of Health and Human Services. Under no circumstances will we retaliate against you for filing a complaint with us or with the Office for Civil Rights.
If you would like more information about your privacy rights, are concerned that we may have violated your privacy rights, or disagree with a decision we may have made about access to your PHI, you may contact White Tree Medical at 801-877-0705 or by mail at:
White Tree Medical
10421 South Jordan Gateway, Suite 660
South Jordan, UT 84095
Change to Notice
White Tree Medical may make changes to the terms of this notice at any time. If a change is made, the clinic may offer a new policy statement and include any information created or received prior to issuing the new notice. Required changes will be posted prominently throughout the clinic and at www.whitetreemedical.com