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 Rights: Summary
You have the right to:
Our Uses and Disclosures
We may use and share your information as we:
Your Rights: Explained
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
1. Get a copy of your medical record
2. Ask us to correct your medical record
3. Request confidential communications
4. Ask us to limit what we use or share
5. Get a list of those with whom we’ve shared information
6. Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly
7. Choose someone to act for you
Your Choices: Explained
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
If you are not able to tell us your preference, for example If you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways:
1. Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
2. Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
3. Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance pion so it will pay for your services.
4. How else can we use or share your health information?
We are allowed or required to share your information in other ways- usually in ways that contribute to
the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
We can use or share your information for health research.
To comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants
to see that we are complying with federal privacy law.
Address law enforcement and other government requests We can use or share health information about you:
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena unless otherwise prohibited from doing so.
Our Responsibilities: Explained
You can contact Lifeback’s Privacy Officer, the Clinical Director, if you think Lifeback has violated your rights.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon
request, in our office, and on our website.
Federal confidentiality regulations, CFR 42, Part 2, provides stricter limits on disclosure of information than HIPAA for Lifeback patients who
are receiving treatment for a substance use disorder. With certain exceptions including, but not limited to, suspicion that you are at imminent risk
of harming yourself, another person(s), or the property of another person(s); suspicion that you are or have perpetrated child or elder abuse or
neglect, or in the event of a medical emergency, Lifeback cannot disclose any information about you unless you have signed a records release
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Lifeback’s HIPAA Notice of Privacy Practices.
I understand that if I have any questions regarding the Notice or my privacy rights, I may contact Lifeback’s Clinical Director.