AZOVA Care Group Notice of Privacy Practices

Your Rights
You have the right to:

• Get a copy of your electronic medical record
• Correct your electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act on your behalf
• File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide mental health care
• Market our services and sell your information

Our Uses and Disclosures
We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Continue reading for more detailed information…

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record

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

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

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

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

• You can ask for a list (accounting) of the times we’ve shared your health information 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, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Upon request, we will provide you with a paper copy promptly.

• 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 action.

• You can complain if you feel we have violated your rights by contacting us.
• 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/
• We will not retaliate against you for filing a complaint.

Your Choices

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.

• Share information with your family, close friends, or others involved in your care (or not to)

If you are not able to 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 health or safety.

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In addition, mental health records may be withheld from you if your provider determines that disclosure would be detrimental to you.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you shares your vaccination record with another doctor or a doctor who is treating you shares your laboratory results with another doctor who is requesting it on your behalf.
Run our organization
We can use and share your health information to run our practice, improve your care, and to contact you when necessary. Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information 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. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues

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

Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests

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

Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it upon request.
• We never sell identifiable personal information.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind, and your updated instructions will apply to any future requests for information that we receive.
• Federal and state laws may place additional limitations on the disclosure of your health information related to drug or alcohol abuse treatment programs, sexually transmitted diseases, genetic information, or mental health treatment programs. When required by law, we will obtain your authorization before releasing this type of information.
• For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be vailable upon requesta.

Patient Bill of Rights

Many states have adopted a patient bill of rights applicable to patients of physicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to the Service is provided to you here on behalf of Laura Purdy - AZOVA Patient Services,Walmart At-Home Testing . Please note that it includes patient responsibilities as well.

• A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
• A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.
• A patient has the right to know who is providing medical services and who is responsible for his or her care.
• A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
• A patient has the right to know what rules and regulations apply to his or her conduct.
• A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
• A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.
• A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.
• A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.
• A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.
• A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
• A patient is responsible for reporting unexpected changes in his or her condition to the Provider.
• A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• A patient is responsible for following the treatment plan recommended by the Provider.
• A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.

State Specific Notifications (See Below For State Specific Mental Health Notifications)

FOR CALIFORNIA RESIDENTS

You or your legal representative retains the option to withhold or withdraw consent to receive health care services via the Service at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which you or your legal representative would otherwise be entitled.
All existing confidentiality protections apply.
All existing laws regarding patient access to medical information and copies of medical records apply.
Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
All provisions herein, including your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit.
NOTICE
Medical doctors are licensed and regulated by the Medical Board of California
(800) 632-2322
www.mbc.ca.gov

FOR FLORIDA RESIDENTS

Each provider’s hours are variable. To access a provider’s in-office schedule, go to that provider’s login page where the provider’s in-office hours are posted.

FOR GEORGIA RESIDENTS

Patient Right to Know
The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The patient should be able to provide the physician or practice name, the address, and the specific nature of the complaint.

FOR INDIANA RESIDENTS

Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.
I expressly consent to providers forwarding my patient identifiable information to the third party payor responsible for the Service or its designee. I agree that I will hold harmless said payor(s), AZOVA Inc., and Provider for any loss of information due to a technical failure.
Notice Concerning Complaints
You may either file a complaint online or download the appropriate complaint form found at http://www.indianaconsumer.com/filecomplaint.asp. If downloading, you must complete, sign, print, and mail it, along with copies of all relevant supporting documentation to:
Consumer Protection Division
Office of the Indiana Attorney General
302 W. Washington St., 5th Floor
Indianapolis, IN 46204
You can also request a complaint form by calling 800-382-5516 or 317-232-6330.

FOR KANSAS RESIDENTS

Notice to Patients: Required Signage for K.A.R. 100-22-6
Prepared by the State Board of Healing Arts
April 5, 2007
NOTICE TO PATIENTS
It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas.
Questions and concerns regarding this professional practice may be directed to:
KANSAS STATE BOARD OF HEALING ARTS
235 S. Topeka Boulevard
Topeka, Kansas 66603
PHONE: (785) 296-7413
TOLL FREE: 1(888) 886-7205
FAX: (785) 296-0852
WEBSITE: www.ksbha.org

FOR LOUISIANA RESIDENTS

The relationship between you and a telemedicine Provider who is not your primary care provider is not intended to replace the relationship between you and other providers. In the event that you see a provider who is not your primary care provider only for a telemedicine service, the relationship between you and the telemedicine Provider is supplemental. Your primary care physician is responsible for your overall health care management.

FOR MARYLAND RESIDENTS

Our procedure to verify the identification of the individual transmitting the communication:
We verify your identification through the assignment and use of a unique username and password combination. When you sign into the Service, your username and password identify you.
Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to you are personal to you and you must not share them with any other individual.
When you choose a provider, you will register for a soonest available service or you can schedule an appointment time. Provider is hereby providing you with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with you and respond to your questions in real time.

FOR OKLAHOMA RESIDENTS

You always retain the option to withhold or withdraw consent from obtaining health care services via the Service. If you decide that you no longer wish to obtain health care services via the Service, it will not affect your right to future care or treatment, nor will you risk the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Patient access to all medical information transmitted during a telemedicine interaction is guaranteed by the provider and copies of this information are available at stated costs, which shall not exceed the direct cost of providing the copies.
All existing confidentiality protections apply.
Dissemination of any of your identifiable images or information from the healthcare interactions including telemedicine services, in office, house call or other services, to researchers or other entities shall not occur without your consent or as allowed by the law.

FOR SOUTH DAKOTA RESIDENTS

SHOULD ANY PATIENT WISH TO DISCUSS FEES OR CHARGES, YOU ARE ENCOURAGED TO ASK ABOUT THEM.

FOR TEXAS RESIDENTS

An additional in-person medical evaluation may be necessary to meet your needs if the provider is unable to gather all the clinical information via the Service to safely treat you.
Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.
You can find information regarding communications such as emails or secure messages in the welcome message on your messaging tab with each provider when you register for a service with that provider.
NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:
Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018
Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353
For more information please visit our website at www.tmb.state.tx.us
AVISO SOBRE LAS QUEJAS
Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos en la Junta de Examinadores Médicos del Estado de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas:
Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018
Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353
Para obtener más información, viwebsite nuestro sitio web en www.tmb.state.tx.us

FOR VIRGINIA RESIDENTS

We are happy to maintain your records while you are an active patient or to transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. We consider patients inactive if they either ask to have their records transferred or they have not been seen in any of our offices for six years. Our policy is to destroy inactive medical records in accordance with the Virginia Department of Health Professions regulations.
These regulations (18VAC85-20-26) state that practitioners must maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:
1. Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;
2. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or
3. Records that are required by contractual obligation or federal law to be maintained for a longer period of time.
Practitioners must post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records can only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. For more information from the Virginia Department of Health Professions, go to www.dhp.virginia.gov/Medicine.

FOR WISCONSIN RESIDENTS

Patients have the right to receive information regarding fees charged for a health care service, diagnostic test, or procedure identified by the patient and provided by the Provider.

FOR COLORADO RESIDENTS

You do not have the right to access your mental health records, but you may receive a summary of such records after termination of the treatment program.

FOR DISTRICT OF COLUMBIA RESIDENTS

Your written authorization is required (and you provide it by agreeing to AZOVA Inc.’s Terms of Use in regards to disclosures required for treatment, payment and health care operations) for disclosure of mental health information. You are entitled to receive a copy of your mental health record within 30 days of submitting a request, though this can be limited by the mental health professional who is primarily responsible for your treatment and diagnosis and which may be imposed only if necessary to protect you or someone else from substantial or significant risk of imminent and serious physical injury.

FOR HAWAII RESIDENTS

Mental illness, mental health, alcoholism and drug addiction records that directly or indirectly identify you shall be kept confidential. Only under limited circumstances, including with your consent or the consent of your legal guardian, may these records be disclosed. Disclosures to third party payors may only be disclosed if you are given the opportunity to pay directly and are informed. If you are a self-pay patient, then no disclosure will be made to third party payors. If you are given access to the services by an arrangement with an employer or a payor and a third party pays for a portion or for all of the cost of your mental health services, then by your accessing the services, you are agreeing and consenting to our disclosure of as much information that is required to secure payment for such services.

FOR MICHIGAN RESIDENTS

As long as you have not been found incompetent and do not have a guardian, you have the right to your mental health records. Provider will provide the records to you within 30 days of receipt of your request, or if you request the records during a course of treatment, by the conclusion or other termination of your course of treatment, if earlier.

FOR MINNESOTA RESIDENTS

Upon written request of your spouse, parent, child or sibling, if you are evaluated for or diagnosed with mental illness, provider must ask you whether you wish to authorize a specific individual to receive information regarding treatment. If authorized, provider shall communicate about your treatment with such individual. In addition, a Provider providing mental health treatment may disclose limited information to a family member/other person if: the request is in writing; the person lives with, provides care for, or is directly involved in your treatment and that involvement is verified by and documented in the medical record; before disclosure, you are informed in writing of the request, the person making the request, and the reason for the request; your agreement, objection or inability to consent or object is documented in the patient’s record; and disclosure is necessary for the patient’s treatment.

FOR SOUTH DAKOTA RESIDENTS

You have the right of access to your mental health records upon request