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VIRGINIA PREVENTIVE MEDICINE AND WELLNESS 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.

Dear Patient:

Virginia Preventive Medicine and Wellness, LLC, a Virginia limited liability company (“we”, “us”, “our”, “Practice”), understands that patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to Practice and each of our Business Associates, as applicable.

Protected Health Information

Protected health information (“PHI”) relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and services that you receive.

Our Obligations Regarding Your Protected Health Information

We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create.

We are required by law to preserve the privacy and security of your PHI. While there is no absolute guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures.

Federal law mandates that we share this Notice with you, and that we make a good faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. In the event that we are involved in a breach of your PHI, we will immediately notify you.

Notice Effective Date and Potential Changes

This Notice became effective on December 1, 2020, and it applies to health records that we create for you. We reserve the right to change this Notice after the effective date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.

How We May Disclose Your Protected Health Information

The laws of the state where Practice is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:

Treat you

We can use your PHI and share it with other professionals who are treating you.

  • Example: A doctor treating you for an injury asks another doctor about your overall health

Run our organization

We can use and share your PHI to run our Practice, improve your care, and contact you when necessary.

  • Example: We use health information about you to manage your treatment and

Bill for your services

We can use and share your PHI to bill and obtain payment from health plans or other entities.

  • Example: We give information about you to your health insurance plan so it will pay for your

Help with public health and safety issues

We can share your PHI for certain situations such as:

  • Preventing disease;
  • Helping with product recalls;
  • Reporting adverse reactions to medications;
  • Reporting suspected abuse, neglect, or domestic violence; and
  • Preventing or reducing a serious threat to anyone’s health or

Perform research

We can use or share your PHI for health research.

Comply with the law

We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests

We can share your PHI with organ procurement organizations. Work with a medical examiner or funeral director.

We can share your PHI with a coroner, medical examiner, or funeral director when an individual dies.

Address other government requests

We can use or share your PHI:

  • For workers’ compensation claims;
  • For law enforcement purposes or with a law enforcement official;
  • With health oversight agencies for activities authorized by law; and
  • For special government functions such as military, national security, and presidential protective

Respond to lawsuits and legal actions

We can share your PHI in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your PHI?

We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. We have not listed every use and disclosure in this Notice.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Use and Disclosure of Your PHI with Your Verbal Agreement

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care;
  • Share information in a disaster relief situation; and
  • Include your information in a hospital

If you cannot tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to your health or safety.

Use and Disclosure of Your PHI Requiring Your Written Permission

If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission:

  • Marketing purposes;
  • Sale of your information; and
  • Most sharing of psychotherapy

With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.

Your Rights Regarding Your PHI

You have the following rights regarding your PHI that is created in our Practice. This section explains some of your rights and our responsibilities to assist you.

Get an electronic or paper copy of your medical record

  • You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your PHI, usually within 30 days of your request. We may charge a reasonable cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do
  • We may say “no” to your request, but we will tell you why in writing within 60

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address.
  • We will say “yes” to all reasonable

Ask us to limit what we use or share

  • You can ask us not to use or share certain PHI in connection with our
  • We are not required to agree to your request, and we may say “no” if it would affect your
  • Because you are privately paying for some medical or health services, you may ask us to refrain from sharing information related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws.

Get a list of who we have shared information

  • You can ask for a list (accounting) of the times we have shared your PHI for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, health care operations, and certain other disclosures (such as any you asked us to make).
  • We will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this Notice

  • You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically. We will provide you with a paper copy promptly.

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 sure the person has this authority and can act for you before we take any

Ask questions of file a complaint if you believe your rights are violated

  • If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately:

Practice Contact Information:

Virginia Preventive Medicine and Wellness, LLC Attention: Dr. Mitchell Mimier

10431 Patterson Ave

Henrico, VA 23238

Email: [email protected]

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.

 

VIRGINIA PREVENTIVE MEDICINE AND WELLNESS ELECTRONIC COMMUNICATIONS AGREEMENT

Virginia Preventive Medicine and Wellness, LLC, a Virginia limited liability company (“we”, “us” or “Practice”) whose sole owner is Dr. Mitchell Mimier, a licensed DO authorized to practice medicine in Virginia, and the undersigned patient (“you” or “Patient”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as e-mail, mobile or cellular telephone, Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication or telehealth or virtual care for the purposes of ongoing routine health exams, related exam scheduling, lifestyle heath guidance, and prescriptions as indicated by exams (collectively “E- Communications”) with respect to Patient protected health information (“PHI”). (Practice and Patient are each individually called “Party” or collectively as “Parties”).

PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH

Patient acknowledges that Practice shall determine when Electronic Communications are appropriate. While Practice and Patient commonly rely on electronic communication platforms and services to achieve immediate communication, there are risks that you acknowledge that are outside the Practice’s control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otherwise in writing. You acknowledge that the use of E-Communications are inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any absolute guaranty of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.

You agree to undertake efforts to protect your privacy, which include refraining from including sensitive information in E-Communications that you do not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect your privacy to the extent required by applicable laws. You authorize us to respond electronically to all E-Communications that appear to be provided by you, whether or not such communications arrive from the electronic contact information that you provide us.

PATIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION

You agree to provide us with your accurate electronic contact information (mobile telephone number for phone calls and text messaging, email address, Skype or FaceTime or other platform contact information, and any other applicable E-Communications contact information). You will immediately inform us of any changes or corrections to your electronic contact information as an effort to avoid misdirected E-Communications.

PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATIONS IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM

Practice does not guarantee that we will read your E-Communications immediately or within any specific amount of time. You agree not to utilize E-Communications to contact us regarding an emergency or time-sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency, immediately seek emergency medical attention, or both.

PRACTICE WILL COMPLY WITH HIPAA

The Practice values and appreciates your privacy and will take commercially reasonable steps to protect Patient’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and other related data privacy laws (“HIPAA”). To the extent required by HIPAA, Practice shall utilize security features toward ensuring Patient health data security (these features may include encryption, password protection, lost device location and/or shut-down features, and authentication techniques).

We will obtain your express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward your identifiable PHI to any third party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law. You hereby consent to the use of E- Communications of Patient’s information as we consider it helpful to coordinate care and schedule mobile visits with you and all those responsible for providing or overseeing your care. You agree to identify individuals or entities authorized to receive your PHI from us in connection with authorized consulting, education, and all other aspects of your care, and we may share your PHI with such parties without additional written or electronic consent from you.

You have the right to ask us for a copy of your PHI, including an explanation or summary. These services that we perform will not be the subject of additional charges to you: maintaining PHI storage systems; recouping capital or expenses for PHI data access, PHI storage, and infrastructure; or retrieval of PHI electronic information.

We may charge you fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include, to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media (with media costs charged to you); and time spent by our administrative staff preparing additional explanations or summaries of PHI. If you request PHI on a paper copy, or portable media (such as compact disc/CD, or universal serial bus/USB flash drive), we may charge you for our actual supply costs for such equipment, and you agree to pay us any such costs.

PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATIONS RISKS

To the extent enforceable under applicable laws, you hold Practice (and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees arising out of or caused by E-Communications (whether encrypted or not) losses or disclosures caused by any of the risks outlined above, by some person or entity other than Practice, or not directly caused by us and/or due to technical failures outside of Practice’s control. Patient acknowledges and understands that, at our discretion, E-Communications may or may not become part of your permanent medical record. These terms do not relieve Practice from Practice’s obligations to comply with all applicable E-Communications laws.

You acknowledge that your failure to comply with the terms of this EC Agreement may result in our terminating the use of E-Communications methods with you and may cause the termination of your agreement for our services.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required to provide you a copy of our Notice of Privacy Practices, which states how we may disclose your health information. You hereby acknowledge receipt of the Notice of Privacy Practices.

CONSENT TO DISCLOSURE OF BILLING INFORMATION

By signing this EC Agreement, you consent to Practice disclosing all information relevant to billing, insurance, and reimbursement regarding any and all substance abuse disorders that you might have, for the purpose of obtaining reimbursement from private or public insurers.

ADDITIONAL TERMS

This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.

Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by you. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.

Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties further agree that this EC Agreement cannot be changed, modified or discharged except by an agreement in writing and signed by both Parties.

If any term of this EC Agreement is deemed invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall remain in full force and effect, and this EC Agreement shall be deemed amended to conform to any applicable law.

Thank you,

VIRGINIA PREVENTIVE MEDICINE AND WELLNESS