Notice of Privacy Practices

If you have any questions or concerns or require additional information after reading this Notice of Privacy Practices, or if you believe that your privacy has been compromised in any way, please contact us immediately:


Pore House, LLC

Boston, MA

Email: hello@meetporehouse.com


About this Notice of Privacy Practices


We are required by law to maintain the privacy of your Protected Health Information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”) explaining our privacy practices with regard to your PHI. “Privacy practices” refers to the ways in which we may use and disclose your PHI. This Notice explains your rights and our legal obligations regarding the privacy of your PHI. We are required by law to abide by the terms of this Notice. We are also required by law to notify you following any breach of privacy of your PHI. If you are a minor, or otherwise incapacitated, we will notify your parent/guardian, or other person responsible for you.


What is PHI?


PHI is information that individually identifies you which we create or obtain from you or another health care provider or health plan, your employer, or a health care clearinghouse, and which relates to (1) your past, present, or future physical or mental health conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.


Uses and Disclosures of Your PHI Which Do Not Require Your Authorization


  1.   Treatment.    We may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your care.

  1.   Payment.    We may use and disclose your PHI so that we can bill you or any third-party payer for the treatment and services you receive from us and can collect payment from you, a health plan, or any third-party payer.

  1.   Health Care Operations.    We may use and disclose your PHI for our operations, which are activities that are necessary to run our practice.

  1.   Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services.    We may use and disclose your PHI to contact you to remind you that you have or are due/overdue for an appointment with our practitioner(s); or to tell you about possible treatment options, alternatives, or health-related benefits and services that may be of interest to you.

  1.   Minors.    We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

  1.   Research.    We may use and disclose your PHI for research purposes, but we will only do so if the research has been specially approved, and we permit researchers to look at your PHI to help them prepare for the research.

  1.   As Required by Law.    We will disclose your PHI when required to do so by international, federal, state, or local law, or by any court order.

  1.   To Avert a Serious Threat to Health or Safety.    We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. We will only disclose your PHI to someone who may be able to help prevent the threat.

  1.   Business Associates.    We may disclose your PHI to our business associates who perform functions on our behalf or provide us with services if your PHI is necessary for those functions or services. For example, we may use another company to do our billing, or to provide consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your PHI.

  1.   Military and Veterans.    If you are a member of the armed forces, we may disclose your PHI as required by military command authorities. We also may disclose PHI to the appropriate foreign military authority if you are a member of a foreign military.

  1.   Workers’ Compensation.    We may use or disclose your PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.

  1.   Public Health Risks.    We may disclose your PHI for public health activities, which include disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety, or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury, or disability; (3) report births and deaths; (4) report child abuse or neglect, elder abuse or neglect, disabled persons abuse or neglect, or rape or sexual assault; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and (8) to report abortions performed after 24 weeks of pregnancy to state government agencies as required by law.

  1.   Abuse, Neglect, or Domestic Violence.    We may disclose your PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.

  1.   Health Oversight Activities.        We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

  1.   Data Breach Notification Purposes.    We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your PHI.

  1.   Lawsuits and Disputes.    If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We also may disclose your PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get a court order for the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit.

  1.   Law Enforcement.    We may disclose your PHI, so long as applicable legal requirements are met, for law enforcement purposed as required by law or in compliance with a court order or a grand jury or administrative subpoena.

  1.   Military Activity and National Security.    If you are involved with the military, national security, or intelligence activities, or if you are in law enforcement custody, we may disclose your PHI to authorized officials so that they may carry out their duties under the law.

  1.   Coroners, Medical Examiners, and Funeral Directors.    We may disclose your PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties.

Uses and Disclosures of Your PHI Which Require Us to Give You an Opportunity to Object and Opt Out


  1.   Individuals Involved in Your Care or Payment for Your Care.        Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, any of your PHI which directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose your PHI as necessary if we determine that it is in your best interest based on our professional judgment.

  1.   Disaster Relief.    We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever it is practical for us to do so.




Uses and Disclosures of Your PHI Which Require Your Authorization


  1.   Highly Confidential Information.    Federal and state law requires special privacy protections for disclosure of certain highly-confidential information about you for any purpose, including treatment, payment, or health care operations purposes. We must obtain your separate and specific consent for the release of this information, unless we are otherwise required or permitted by law to make the disclosure. Your highly confidential information includes:

  1.   HIV/AIDS status;
  2.   Mental/Behavioral health documentation;
  3.   Genetic testing information;
  4.   Communications with a psychotherapist, psychologist, social worker, allied mental health professional, or human services professional;
  5.   Substance abuse (alcohol or drug) treatment or rehabilitation information;
  6.   Venereal disease information;
  7.   Abortion records;
  8.   Mammography records;
  9.   Family planning services;
  10.   Treatment or diagnosis of emancipated minors;
  11.   Mental health community program records; and
  12.   Research involving controlled substances.

  1.   Uses and Disclosures of PHI for Marketing Purposes.    We must obtain your written authorization prior to using your PHI to send you marketing materials. However, we can provide you with marketing materials in a face-to-face encounter without authorization. We can also give you a promotional gift of nominal value without your authorization. In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers, or care settings without your authorization. We may also use PHI to identify health-related services and products that may be beneficial to your health and then contact you about those services and products.

  1.   Disclosures that Constitute a Sale of Your PHI.    We will not sell your PHI to any third-party without your authorization.

  1.   Other Uses and Disclosures.        We must obtain your written authorization for other uses and disclosures of your PHI not covered by this Notice or the applicable laws. If you do give us authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer; and we will no longer disclose your PHI under the authorization. However, disclosures made in reliance on your authorization prior to revocation will not be affected by the revocation.


Your Rights Regarding Your PHI


You have the following rights, subject to certain limitations, regarding your PHI:


  1.   Right to Inspect and Copy.        You have the right to inspect and copy records of your PHI. Upon your receipt of your written request, we have up to thirty (30) days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed health care professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. All requests must be made in writing. Certain information (e.g., psychotherapy notes) may be withheld from you in certain circumstances.

  1.   Right to a Summary of Explanation.    Upon receipt of your written request, we can provide you with a summary of your PHI, rather than the entire record, or an explanation of your PHI, so long as you agree to the summary or explanation and pay the associated fees. All requests must be made in writing.

  1.   Right to an Electronic Copy of Electronic Medical Records.    If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request, your record will be provided in either our standard electronic format of if you do not want our standard electronic format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. All requests must be made in writing.

  1.   Right to Notice of a Breach.        You have the right to be notified of any breach of any of your unsecured PHI.

  1.   Right to Request Amendments.    If you feel that the PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. A request for an amendment must be made in writing to our Office Manager at the address provided at the beginning of this Notice. The request must provide a reason for the requested amendment. In certain cases, the request may be denied. For example, if we believe that the information that would be amended is accurate and complete or other special circumstances apply, we would deny the request. If we deny the request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

  1.   Right to an Accounting of Disclosures.    You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we have made of your PHI. This right applies to disclosures for purposes other than treatment, payment, or health care operations as described in this Notice. It excludes disclosures we may have made to you, to family members involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions, and limitations. We are not required to provide you with an accounting of disclosures that were made more than six (6) years prior to the date of the request. We will provide the first accounting of disclosures that you request in any twelve (12) month period free of charge. However, we may impose a reasonable, cost-based fee for each subsequent accounting of disclosures that you request within the same twelve (12) month period. We will inform you of the amount of any such fee prior to providing the accounting of disclosures, and you may choose to withdraw or modify the request before the costs are incurred.

  1.   Right to Request Restrictions.    You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a restriction or limitation on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member. You may also request a restriction or limitation on our use or disclosure of PHI for purposes of notifying or assisting in the notification of such individuals regarding your location or general condition. To request a restriction on who may have access to your PHI, you must submit a written request to our Office Manager. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If you request a limitation on certain family members, we may not be able to bill your family’s health plan and you will have to be financially responsible to pay us for the care we provided to you. You may not ask us to restrict disclosures that we are legally required to make. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.

  1.   Right to Limit Disclosures of PHI for Which You Paid Out-of-Pocket.        If you paid out-of-pocket (and have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

  1.   Right to Request Confidential Communications.        You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.

  1.   Right to a Paper Copy of This Notice.    You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

  1.   Right to Revoke Your Authorization.    You may revoke any authorization you have provided by providing a written revocation to our Office Manager. However, such revocation does not apply to uses or disclosures made in reliance on authorization given prior to revocation.

How to Exercise Your Rights


To exercise your rights as described in this Notice, send your request, in writing, to our Office Manager at the address listed at the top of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your PHI, you may also contact your practitioner directly. To get a paper copy of this Notice, contact our Office Manager by telephone, electronic mail, or regular mail.


Changes to this Notice of Privacy Practices


We reserve the right, at any time and within our sole discretion, to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our website.


Complaints


To file a complaint, please contact our Office Manager by telephone, electronic mail, or regular mail. All complaints must be made in writing and should be submitted within One Hundred and Eighty (180) days of when you knew or should have known of the suspected violation.


You also have the right to file a complaint with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with the Secretary, mail it to:


Secretary of the U.S. Department of Health and Human Services

200 Independence Ave, S.W.

Washington, D.C. 20201.


You can also file a complaint with the Secretary by calling (202) 619-0257 (or toll free (877) 696-6775). You can visit the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.


This Notice is effective as of the date on which you receive it.



Pore House Acknowledgment of Receipt of Notice of Privacy Practices (NPP)

 

Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. By signing this form you acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

 

We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so.

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