Greeneville Integrative Medicine

1017 Tusculum Blvd. Suite 1 Greeneville, TN 37745

Michelle Dilks, D.O.

Phone:423-823-9629/ Fax: 423-525-4366

Notice of Privacy Practices

Effective Date: July 1, 2019

Who Will Follow This Notice: This notice summarizes the privacy practices of the members of Greeneville Integrative Medicine, PLLC. This notice applies to all healthcare professionals and others who may be involved directly or indirectly in your care at Greeneville Integrative Medicine such as employees, physicians, residents, students and volunteers, and others affiliated with Greeneville Integrative Medicine when providing services at the Greeneville Integrative Medicine facility.

Our Pledge to You: We understand that your health information is personal, and we are committed to protecting its privacy. We are required by law to: • Maintain the privacy of your health information. • Give you this notice of our legal duties and privacy practices regarding your health information. • Follow the terms of our Notice of Privacy Practices that are currently in effect; and • Notify you following a breach of your unsecured health information. Your Rights Regarding Health Information About You:

Right to Inspect and Copy: You have the right to request to inspect and obtain a paper or electronic copy of the health information that may be used to make decisions about your care or payment, and to request that a copy be forwarded to a third party of your choice. However, under certain circumstances and, if permitted by law, we may deny your request. To inspect and obtain a copy of your health information, you must submit your request in writing. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request, or less as required by state law. There may be reasonable, cost-based fees for the costs of copying, mailing or other supplies associated with your request.

Right to Amend: If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information as long as it is kept by Greeneville Integrative Medicine. To request an amendment, your request must be made in writing and provide a reason that supports your request. Ask us how to submit this request. We may deny your request under certain circumstances. You will be informed of the decision regarding any request for amendment of your health information within 60 days and, if we deny your request for amendment, we will provide you with information regarding your right to respond to that decision.

Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we make of your health information. We will include all disclosures except those for treatment, payment, healthcare operations, and certain other disclosures (such as those you asked us to make). To request this list of disclosures, you must submit your request in writing to the healthcare provider or facility. Your request must state a time period for which the accounting of disclosures is sought, which cannot be longer than six years prior to the date on which your request for accounting is made.

Right to Request Restrictions: You have the right to request a restriction on the health information we use or disclose about you for treatment, payment, healthcare operations, to persons involved in your care or payment, or disclosures for disaster relief purposes. We are not required to agree to a request for restrictions, other than a request that we not disclose information to a health plan for payment or health care operations where the request relates only to a health care item or service for which we have been paid in full. We will notify you if we don’t agree to your request for restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the healthcare provider or facility. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your health plan.

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. For example, you can ask that we contact you only by mail or at work. Your request must be in writing and specify how or where you wish to be contacted and to what address we may send bills for payment for services provided to you. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

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. We will make reasonable efforts to ensure the person has this authority and can act for you before we take any action.

How Your Health Information May Be Used and Disclosed Without Your Authorization: The following describes different ways that Greeneville Integrative Medicine is permitted to use and disclose health information that identifies you.

Treatment: We may use health information to treat you or provide you with healthcare services. For example, we may tell your primary care physician about the care we provided you or give health information to a specialist to provide you with additional services.

Payment: We may use and disclose health information so that we or others may bill or receive payment from you, an insurance company or a third party for the treatment and services provided to you. For example, we may disclose your health information to an ambulance company, so that the ambulance company can receive payment for services provided to you.

Individuals Involved in Your Care or Payment for Your Care: If you do not object, or we reasonably infer, based on professional judgement, that you do not object to the disclosure, we may disclose relevant health information to a family member, friend, or other person involved in your medical care or who helps pay for your care. We may also disclose health information to a personal representative, who is a person who has legal authority to make healthcare decisions on your behalf.

Research: Under certain circumstances, we may use and disclose health information for research purposes provided we comply with applicable federal and state legal requirements.

Other Purposes: We may use or disclose health information about you for other reasons:

• In a disaster relief situation. • When required by international, federal, state or local law, including a request by the Secretary of the Department of Health and Human Services to see that we are complying with federal privacy law. • To avert or reduce a serious threat to health or safety of the public or another person. • For special government functions such as national security and intelligence activities, including presidential protective services. • For a member of the Armed Forces (domestic or foreign), we may disclose your medical information as required by military command authorities. • In response to a court or administrative order, subpoena or other lawful process. • To a law enforcement official for law enforcement purposes provided we comply with applicable legal restrictions. • To report child or elder abuse or neglect or domestic violence if we reasonably believe that you are a victim and to the extent required or permitted by federal or state law. • If you are an inmate, to the correctional institution or law enforcement official. • To an organ donation bank or to facilitate organ or tissue donation and transplantation. • To workers’ compensation or similar programs for work-related injuries or illness to the extent necessary to comply with laws related to these programs. • For public health activities such as to prevent or control disease, injury or disability; to report births and deaths; to notify a person who may have been exposed or who may be at risk of spreading a disease; or reporting information to the Food and Drug Administration (FDA) if you experience an adverse reaction from any drugs, supplies or equipment. • To health oversight agencies for activities authorized by law. • To a coroner/medical examiner as authorized by law to identify a deceased person or determine cause of death. • To funeral directors to carry out their duties.

Uses and Disclosures of Medical Information Which Require Your Authorization: Uses and disclosures of health information that are not discussed by this notice or required by law will only be made with your written permission. Your written authorization will typically be required for most uses and disclosures of psychotherapy notes, most uses and disclosures for marketing and most arrangements involving the sale of health information.

How You May Revoke Your Authorization: If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. Your request to revoke your authorization must be sent to our privacy officer or corporate compliance officer.

Confidentiality of Substance Use Disorder Patient Records: We may not identify that you receive services at a substance use disorder program, or disclose any information from a program identifying you as receiving substance use disorder treatment unless: (1) You consent in writing: (2) The disclosure is allowed by a court order; or (3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the federal law and regulations governing the confidentiality of substance use disorder treatment records is a crime. Suspected violations may be reported to: U.S. Attorney for the Eastern District of Tennessee, 800 Market Street, Suite 211, Knoxville, TN 37902 or, for opioid treatment programs, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment, 5600 Fishers Lane, Rockville, MD 20857, 240.276.1660.

Federal law and regulations governing substance use disorder treatment records do not protect: • Any information about a crime committed by a patient either at the treatment program or against any person who works for the program, or about any threat to commit such a crime. • Any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

(See 42 U.S.C. 290dd–3 and 42 U.S.C. 290ee–3 for Federal laws and 42 CFR part 2 for Federal regulations governing the privacy of substance use disorder treatment records.)

Changes to This Notice: We reserve the right to change this notice and the revised or changed notice will be effective for health information we already have about you as well as any information we receive in the future. The effective date is noted on the first page. You may request a copy of the new notice be sent to you in the mail or electronically.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.

Discrimination is Against the Law

Greeneville Integrative Medicine complies with federal civil rights laws and does not discriminate, exclude people, or treat them differently because of age, race, color, national origin, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression.

If you believe that Greeneville Integrative Medicine has failed to provide these services or discriminated on the basis of age, race, ethnicity, religion, color, national origin, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression, You can file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

 

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.