EMPACT-SPC

Notice of Privacy Practices

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.

This notice is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how we may use or disclose your protected health information, and with whom we may share that information. This also describes your right to access and amend your protected health information, and receive an accounting of disclosures of it.

As described below, you may have the right to object to some of our practices

This information will be made available to you at our treatment sites when treatment is started, and when services are begun at locations outside of our treatment sites, (but not during an emergency situation). In that case, we will do so as soon as the emergency treatment situation is resolved. Our notice will also be posted on our Internet site http://www.empact-spc.com. You may obtain a copy of this notice by asking for it at your next appointment, or calling EMPACT-SPC at (480) 784-1514.

Our Duties To You Regarding Your Protected Health Information

Protected Health Information generally is individually identifiable health information. This information includes information such as age, address, name…etc, and relates to your past, present, or future physical and mental health, payment of health care, and provision of health care. We will take the following actions with regard to that information;

• Make sure it is kept private
  
• Give you information (this notice) about our obligations and practices about how we will use and disclose this information
  
• Follow the terms of the notice that are currently in effect
  
• Communicate any changes in our privacy practices to you
  

We reserve the right to change this notice. The effective date of this notice will be at the top of the first page. We reserve the right to revise or make changes to this notice effective for health information we already have acquired about you and for information we receive about you in the future. We will provide you with a revised notice by having a copy posted in the waiting rooms of our treatment facilities, making a copy available to take with you and by posting it on our web site at http://www.empact-spc.com

How Your Protected Health Information May be Used or Disclosed

We may use or disclose your protected health information in the ways described in this notice. We must also disclose your health information to you unless it has been determined that it would be harmful to you, and to the Secretary of Health and Human Services for investigations or determinations of our compliance with any laws or regulations related to Protected Health Information, or to any other entities whose laws and regulations require us to report information. We may also share this information with business associates who perform certain activities related to providing services to you, such as companies contracted to store records. Our business associates will also be asked to protect your health information.

EMPACT-SPC may also use and disclose your protected health information for the purposes of treatment, payment and operations.

Treatment means:

Providing, coordinating, or managing health care and related services. For example, EMPACT-SPC may disclose medical information about you to another health care provider that has been or becomes involved in your treatment. In emergencies we will use and disclose protected health information to provide the treatment you require.

Payment means:

Activities undertaken by EMPACT-SPC or its business associates to obtain or provide reimbursement for providing health care. These activities include, but are not limited to:

• Determining eligibility or coverage, billing, collection activities, reviewing health care services for medical necessity
  
• Utilization review activities, including reviewing services in advance, while they are being delivered, or after they are delivered, and
  
• Disclosing to consumer reporting agencies any of the following protected health information relating to collection of premiums or reimbursement:
  

A. Name and address
B. Date of birth
C. Social security number
D. Payment history
E. Account number; and
F. Name and address of the health care provider and/or health plan.

For example, we may disclose protected health information in order to obtain reimbursement for services we provided, and to review your care to be certain it is consistent with current practice standards.

Operations includes:

Conducting quality improvement activities, case management, contacting clients with information about treatment alternatives, evaluating the performance of providers conducting training programs, accreditation, licensing, and auditing functions, including fraud and abuse detection, and improving customer service, including resolving complaints. We may use protected health information to call or mail you reminders of a pending appointment, about treatment alternatives or other health-related benefits and services that may be of interest to you, or to contact you after treatment is completed to inquire about your satisfaction with the care and services you received.

Other Situations in Which We May Use or Disclose Your Protected Health Information

The following is a description of other uses and discloses of your protected health information specifically addressed by HIPAA. When required, we will first obtain your written authorization or other form of permission prior to using or disclosing your protected health information.

To You: We may disclose your protected health information to you.

Public Health Authority: We may disclose your protected health information to a Public Health Authority who is permitted by law to receive and collect this information. Some examples of this include;

To report child or adult abuse and neglect
To report reactions to medications or products
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

Coroners, Medical Examiners and Funeral Directors-We may release information to a Coroner or medical examiner to, for example, identify a cause of death.

Specialized Government Functions: We may use and disclose protected health information about you for specialized government functions, such as to authorized health officials for intelligence, counterintelligence, and other national security activities authorized by law, to authorized Federal Officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, under certain circumstances to officials providing care for you if you are an inmate of a correctional institution or if you are a member of the Armed Forces, we may release medical information about you if it is required by military command authorities.

Worker's Compensation- We may disclose your protected health information to comply with worker’s compensation laws and other programs.

Fundraising Activities-We may use medical information about you to contact you in an effort to raise money for EMPACT-SPC and its operations. We may disclose information about you to a business associate or Foundation related to EMPACT-SPC so that the Foundation may contact you to raise money for EMPACT-SPC and its operations. We will only release information such as your

name, address, phone number the dates you received treatment or services at EMPACT-SPC and demographic information. If you do not want to be contacted, please notify us by writing or calling:

Privacy Officer

EMPACT-SPC1232 E. Broadway Rd. Ste. 120Tempe AZ 85282480-784-1514

As Required by Law-We may use or disclose information about you when required to do so by Federal, State or local law.

To prevent a serious threat to health and safety from occurring-We may use and disclose information about you when it is necessary to prevent a serious threat to your health and safety or the health and safety of someone else from occurring. We will only disclose that information to someone who may be able to prevent the threat from occurring.

Legal proceedings- We may disclose protected health information as required during a judicial proceeding, in response to a court order, subpoena, discovery request, or other legal process.

Research-We may use or disclose protected health information if authorized by law, if the research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established procedures to protect the privacy of your health information or if the researcher has provided certain representations and documentation required by HIPAA.

We may disclose your protected health information for law enforcement purposes including:

1. As required by law
2. In response to a Court Order, subpoena, warrant, summons, administrative request or similar process
3. To identify or locate a suspect, fugitive, material witness, or missing person
4. About the victim of a crime, if under certain limited circumstances we are unable to obtain the person’s agreement
5. About a death we believe may be the result of criminal conduct
6. About criminal conduct at our agency
7. In emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Victims of Abuse, Neglect, or Domestic Violence-We may disclose protected health information about an individual we reasonably believe may be a victim of abuse, neglect or domestic violence to a government authority.

Health Oversight Activities-We may disclose your protected health information to a health oversight agency for oversight activities authorized by law, including audits, investigations and inspections.

Cadaveric Organ, Eye or Tissue Donations-We may use or disclose your protected health information to organ procurement organizations or other entities engaged in such activities.

Marketing-We may under certain circumstances use or disclose your protected health information for marketing to you in face-to-face encounters or concerning products or services of nominal value.

Underwriting-We may use or disclose certain protected health information for underwriting and related purposes.

People Involved in Your Care-We may disclose your protected health information to family members, other relatives, close personal friends or other people you identify who are involved in your care or payment related to your care. You may restrict or prohibit any of these disclosures by providing written notice to us at the above-listed address.

Notification of Location, General Condition or Death-We may use or disclose your protected health information to certain persons and entities to notify family members, personal representatives or other persons responsible for your care of your location, general condition or death. You may restrict or prohibit any of these disclosures by providing written notice to us at the above-listed address.

Incidental Uses-We may use or disclose your protected health information when incident to a use or disclosure otherwise permitted by HIPAA.

Other Uses and Disclosures

No other uses or disclosures will be made by EMPACT-SPC without your written authorization. You can revoke or take back that authorization, but it must be done in writing and cannot be revoked in those cases where EMPACT-SPC has already taken action as a result of your authorization. If the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.

You also have the following rights:

You have the right to request that we place additional restrictions on our use and disclosure of your protected health information. We are not required to agree to any restriction that you may request. If we do agree to the restriction, we will comply with the restriction unless the information is needed to provide emergency treatment to you or unless the use or disclosure is otherwise permitted or required by law. Your request must be made in writing. To request a restriction, contact the Privacy Officer at the address listed in the last section of this Notice.

You also have the right to request that we communicate your protected health information to you in an alternative manner or at an alternative location. We will accommodate a request that is reasonable. Your request must be made in writing. To make such a request, contact the Privacy Official at the address listed in the last section of this Notice.

You have the right to inspect and receive a copy of your health information

You have the right to inspect and/or receive a copy of your health information. Your request must be in writing to the Privacy Officer at the address listed in the last section of this Notice. We may charge you related fees. Instead of providing you with a full copy of the protected health information, we may give you a summary or explanation of the information about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.

Information About Your Rights to Request an Amendment of Your Health Information:

If you believe that your protected health information is incorrect or incomplete, you may request that we amend your information. In certain cases, we may deny your request for an amendment for reasons set forth in the HIPAA regulations. For example, we may deny your request if the information you want to amend was not created by us, but by another entity. If we deny your request, you have the right to file a statement of disagreement with us. Your statement of disagreement will be linked with the disputed information and all future disclosures of the disputed information will include your statement. Your request must be made in writing. To request that we amend your protected health information, contact the Privacy Official at the address listed in the last section of this Notice.

Information About Your Rights To An Accounting of Disclosures of Protected Health Information:

You have the right to an accounting of certain disclosures that we have made of your protected health information. You are not entitled to an accounting of disclosures that were made for our payment, or health care operations, pursuant to your authorization, or in certain other limited instances. An accounting of disclosures will include a brief description of the information disclosed, the date of the disclosure, to whom the disclosure was made, and the purpose for the disclosure. Your request must be made in writing. To request an accounting of disclosures, contact the Privacy Official at the address listed in the last section of this Notice.

Complaints and Further Information- You may complain to us and/or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. To complain to us or for further information regarding this Notice of Privacy Practices, submit your complaint or request in writing to the Privacy Officer at the address listed in the last section of this Notice.

You will not be retaliated against for filing a complaint.

This Notice is not intended to limit other applicable federal, state or local laws. Where the other applicable law is more stringent, EMPACT-SPC will apply the more stringent law.

Address of Privacy Officer:

Privacy OfficerEMPACT-SPC1232 E. Broadway Rd. Ste. 120Tempe AZ 85282Phone 480-784-1514