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THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU (AS A PATIENT) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

ImpactLife is dedicated to maintaining the privacy of your Protected Health Information (PHI). In conducting our business, we will create records regarding you and the treatment we provide to you. We are required by law to maintain confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain concerning your PHI. By federal and state law, we must follow the terms of this Privacy Notice.

We must provide you with the following information:

  • How we may use and disclose your PHI.
  • Your privacy rights as they relate to your PHI.
  • Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to patient medical records containing PHI that are created or retained by ImpactLife. We reserve the right to revise or amend this Privacy Notice. Any revision or amendment to this notice will be effective for all medical records that ImpactLife has created or maintained in the past or will create or maintain in the future. We will post a copy of our current notice in our sites in a visible location at all times and on our ImpactLife website. You may request a paper copy of our most current notice at any time.

B. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS

  1. Treatment. ImpactLife may use your PHI to treat you. Many of the people who work at ImpactLife including, but not limited to doctors, nurses and technicians may use or disclose your PHI in order to treat you or to assist others in your treatment. For example, your medical history may be obtained by our staff and recorded in your chart to assist in determining appropriate treatment.
  2. Payment. ImpactLife may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs. We may use your PHI to bill you directly for services and items.
  3. Health Care Operations. ImpactLife may use and disclose your PHI to operate our business. As examples of this, ImpactLife may use your PHI to evaluate the quality of care you received from us, or to conduct cost management and business planning activities for ImpactLife.
  4. Appointment Reminders. ImpactLife may use and disclose your PHI to contact you and remind you of an appointment.
  5. Treatment Options, Health-Related Benefits and Services. ImpactLife may use and disclose your PHI to inform you of potential treatment options or alternatives. ImpactLife may use and disclose your PHI to inform you of health-related services that may be of interest to you.
  6. Release of Information. ImpactLife will require a signed authorization form in order to release your PHI to anyone, including family members, friends or anyone assisting in taking care of you. You may revoke such authorization as provided by 45 C.F.R. § 164.508(b)(5).
  7. Disclosures Required by Law. ImpactLife will use and disclose your PHI when we are required to do so by federal, state or local law. Examples of this include public health risks, health oversight activities, lawsuits, law enforcement, serious threats to health or safety, military, national security and workers’ compensation.

C. YOUR RIGHTS REGARDING YOUR PHI

  1. Confidential Communications. You have the right to request that ImpactLife communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request. You do not need to give a reason for your request.
  2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. You have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or payment for your care. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to ImpactLife Privacy Officer. Your request must describe:
    • The information you wish restricted;
    • Whether you are requesting to limit ImpactLife’s use, disclosure or both; and
    • To whom you want the limits to apply
  3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including medical records and billing records. You must submit your request in writing to ImpactLife. ImpactLife may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. ImpactLife may deny your request to inspect and/or copy records in certain limited circumstances, however, you may request a review of our denial. In this case, a mediator chosen by us will conduct reviews.
  4. Amendment. You may ask us to amend your health information if you believe it to be incorrect or incomplete. Your request for amendment must be in writing and submitted to ImpactLife. You must provide a reason that supports your request for amendment. We may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete, (b) not part of the PHI kept by ImpactLife, (c) not part of the PHI which you would be permitted to inspect and copy, or (d) not created by ImpactLife.
  5. Accounting of Disclosures. You have the right to request an accounting of disclosures made by ImpactLife in the 6 years prior to the date the request for an accounting is made. This is a list of certain non-routine disclosures ImpactLife has made of your PHI for non-treatment or operations purposes. Use of your PHI as part of routine patient care does not require documentation, such as a nurse sharing information with the physician or billing department using your information to file your insurance claim. To request an accounting of disclosures, you must submit your request in writing to ImpactLife. All requests must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list within a 12-month period is free of charge, but ImpactLife may charge for additional lists within the same 12-month period. ImpactLife will notify you of charges involved with additional requests and you may withdraw your request before you incur any costs.
  6. Right to a Paper Copy of this Notice. You are entitled to receive a paper copy this Privacy Notice. You may ask for a copy of this notice at any time. To obtain a paper copy, contact ImpactLife.
  7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with ImpactLife. To file a complaint, contact ImpactLife. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
  8. Right to Provide Authorization for Other Uses and Disclosures. ImpactLife will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain medical records of your care.

If you have any questions regarding this notice or ImpactLife privacy policies, please contact our Quality department at 563-823-4110 or 800-747-5401.