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.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices (the “Notice”) describes Formen Testosterone Health’s (the “Company”) practices and those of Company employees, staff, volunteers, and other personnel who are involved in your care. The Company and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services.
THE COMPANY’S PLEDGE REGARDING MEDICAL INFORMATION
The Company understands that medical information about you and your health is personal. The Company is committed to protecting medical information about you. In order to provide you with quality care and to comply with certain state and federal legal requirements, the Company creates a record of the services you receive at the Company. This Notice applies to all of the records of your care generated by the Company. This Notice will tell you about the ways in which the Company may use and disclose medical information about you. It also describes your rights and certain obligations the Company has regarding the use and disclosure of medical information. The Company is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect, and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
HOW THE COMPANY MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that the Company may use or disclose protected medical information. For each category of uses and disclosures, the Company will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways the Company is permitted to use and disclose information will fall within one of the categories.
For Research. The Company may disclose medical information about you to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information. For Payment. The Company may use and disclose medical information about you so that the Company can get paid for the treatment and services you receive at the Company.
For Health Care Operations. The Company may use and disclose medical information about you to carry out activities that are necessary for Company operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, the Company may use medical information to review treatment and services provided at the Company or to evaluate the performance of its staff and contractors in caring for you.
To Individuals or Family Members Involved in Your Health Care. Unless you object, the Company may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. The Company may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.
Emergencies. The Company may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, the Company will use its professional judgment to decide whether this disclosure is in your best interest.
As Required By Law. The Company will disclose your health information when required to do so by federal, state or local law.
Workers’ Compensation. The Company may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
For Public Health Activities. The Company may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders, and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
For Health Oversight Activities. The Company may disclose medical information about you to a health oversight agency for activities authorized by law.
For Lawsuits and Disputes. The Company may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Disclosure to Law Enforcement. If asked to do so by law enforcement and as authorized or required by law, the Company may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at the Company; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Decedents. The Company may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Company may also release medical information about you to funeral directors. The Company may also release information to any individual known to the Company as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
For Specialized Government Functions. The Company may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.
Information About Inmates/Individuals in Custody. If you are an inmate or under the custody of a law enforcement official, the Company may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
Disclosure For Threats to Health and Safety. In certain circumstances, the Company may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
Marketing. The Company will not release your medical information for marketing purposes without an authorization from you.
Sale of Medical Information. The Company will not sell your medical information without an authorization from you.
You have the following rights regarding your medical information. In order to exercise these rights, you must contact The HIPAA Privacy Officer at the Company. You may be asked to submit a written request. The HIPAA Privacy Officer may be contacted using the following information:
Formen Testosterone Health
9778 Katy Freeway, Suite 250
Houston, TX 77055
Phone: (713) 714-8253
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.
Amendment. If you feel that medical information about you is incorrect or incomplete, you may ask the Company to amend the information.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures that we may have made of your medical information.
Right to Request Restrictions. You have the right to request a restriction or limitation on medical information that the Company uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that the Company may disclose to family members or friends involved in your care.
Request Confidential Communications. You have the right to request that the Company communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.
Receive a Copy. You have the right to obtain a copy of this notice.
CHANGES TO THIS NOTICE
The Company reserves the right to change the terms of this Notice at any time. The Company reserves the right to make the revised or changed notice effective for medical information the Company already has about you as well as any information the Company receives in the future. The Company will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
If you have any questions or believe that your privacy rights have been violated, you may contact the Company’s HIPAA Privacy Officer in person or mail a written summary of your concern to the address listed above.
You may also file a written complaint with the Department of Health and Human Services at the following address:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
Toll-free: (800) 368-1019
TDD toll-free: (800) 537-7697
You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide the Company permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission the Company will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if the Company has already acted in reliance on your permission. You understand that the Company is unable to take back any disclosure the Company has already made with your permission and that the Company is required to retain its records of the care that the Company provided to you.