HIPAA Notice

HEALING PALMS HEALTHCARE LLC

NOTICE OF PRIVACY PRACTICES

Effective: January 1, 2017

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.

Healing Palms Healthcare LLC, its affiliates, subsidiaries and/or divisions (collectively referred to as ” Healing Palms Healthcare LLC”) is required by law to provide you with this notice explaining Healing Palms Healthcare LLC privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment and health care operations, as well as for other purposes that are permitted or required by law. Healing Palms Healthcare LLC is required by law to follow the procedures described in this Notice of Privacy Practices as long as the Notice remains in effect. You have certain rights regarding the privacy of your protected health information and we also describe those rights in this notice.

Healing Palms Healthcare LLC is required to protect the confidentiality of your protected health information and to inform you if your protected health information has been acquired, accessed, used or disclosed by unauthorized persons.

WHAT IS PROTECTED HEALTH INFORMATION?

Protected Health Information (PHI) includes both medical information regarding your care and treatment and individually identifiable personal information such as your name, address, phone number, social security number or other personal information that you provide in the course of your treatment. This informationmay be in electronic, written and/or oral form.

HOW Healing Palms Healthcare LLC MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

Healing Palms Healthcare LLC may use and disclose PHI about you, without your authorization, for the purposes described below.

Treatment: Healing Palms Healthcare LLC may use and disclose your health information to provide, coordinate or manage your healthcare by us and other healthcare providers. This includes, but is not limited to, disclosures about you to doctors, nurses, technicians, staff and other healthcare professionals who become involved in your care. For example: Healing Palms Healthcare LLC or your doctor may determine that you require the assistance of a physical therapist. After we have obtained an order from your doctor, we will contact the therapist and give them the medical and personal information needed to coordinate and provide your care.

Payment: Healing Palms Healthcare LLC may use and disclose your health information to receive payment for services provided to you, or to obtain prior authorizations for proposed treatments. For example: Healing Palms Healthcare LLC may need to provide an insurance company or federally funded program such as Medicare or Medi-Cal, with information about your medical condition and the healthcare you require, in order for Healing Palms Healthcare LLC to receive payment for services rendered by Healing Palms Healthcare LLC.

Healthcare Operations: Healing Palms Healthcare LLC may use your health information for our own operations. We may also use and disclose your health information to health professionals for educational purposes. These uses are required to run our company and to make sure that all of our patients receive quality care. For example: Healing Palms Healthcare LLC may use your health information to review the services we provide, and the performance of our staff involved in your care. Information about you may also be used to develop programs to meet your needs and the educational requirements of our employees.

Treatment Issues: We may call you with test results or to answer your questions about your care, or use and disclose health information to inform you about treatment options and alternatives.

Health-Related Benefits and Services: We may use and disclose personal and health information to tell you about health-related benefits or services that may be of interest to you

Individuals Involved In Your Care or Payment For Your Care: Unless you object,wemay disclose your health information to a relative, friend or any person identified by you, if these individuals need to know about or are involved in your care, or for payment for your care.

Workers Compensation: Healing Palms Healthcare LLC may disclose your health information in order to comply with laws relating to workers’ compensation or similar programs.

Public Health, Safety, Disaster Relief, Or to Divert a Threat to Health Or Safety; Victims of Abuse, Neglect, or Domestic Violence: Healing Palms Healthcare LLC may use or disclose your health information to the extent necessary for public health activities and to avert a serious and imminent threat to your health or safety or the health and safety of others. Healing Palms Healthcare LLC may disclose your personal and health information to the appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes. Any disclosure would only be to someone able to help prevent the threat or injury.

Health Oversight: Healing Palms Healthcare LLC may disclose your health information to a health oversight agency for activities authorized by law. This may include but is not limited to The Joint Commission, ACHC, surveys, investigations, inspections, licensure or disciplinary actions.

Legal Proceedings and Law Enforcement: Healing Palms Healthcare LLC may disclose your health information if asked to do so by a law enforcement officer and/or in response to a subpoena, court or administrative order, warrant, discovery request or other lawful process.

Military and National Security: Healing Palms Healthcare LLC may disclose your health information to authorized military command authorities or federal officials if you are in the armed forces or are a veteran, or as required for lawful intelligence, counter intelligence and other national security activities.

Coroners, Medical Examiners and Funeral Directors: Wemay disclose your health information to a coroner ormedical examiner if necessary to identify a deceased person or to determine a cause of death, or to a funeral director in connection with the performance of their duties.

Business Associates: Healing Palms Healthcare LLC may provide some services through contracts with business associates. In those instances, Healing Palms Healthcare LLC requires the business associates to safeguard your information through a Business Associate Agreement.

Research; Death; Organ Donation: Healing Palms Healthcare LLC may use and disclose your health information for research purposes in limited circumstances. However, all such research projects are subject to an approval process, and we will ask your permission if a researcher is to have access to your name, address, or other information that identifies you. Healing Palms Healthcare LLC may disclose your health information for the purpose of facilitating organ donation and transplantation.

Required By Law: Healing Palms Healthcare LLC will use or disclose your health information when required to do so by federal, state or local law.

USES OR DISCLOSURES NOT COVERED BY THIS NOTICE.

Uses or disclosures of your health information not covered by this notice or the laws that apply to Healing Palms Healthcare LLC may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation.

YOUR RIGHTS REGARDING YOUR PERSONAL AND MEDICAL INFORMATION.

Although your medical record is the property of Healing Palms Healthcare LLC, the information belongs to you. Federal law gives you the rights described below regarding your medical information.

Inspect and Com With some exceptions, you may review and copy your medical information. To the extent your record is maintained electronically, you have the right to access your own electronic health record in an electronic format. You may also direct Healing Palms Healthcare LLC to send the e- health record directly to a third party.

Amendments. You may ask us to amend your medical information if you feel it is incorrect or incomplete. However, we may deny your request under certain circumstances.

Accounting of Disclosures. You may request a list of certain disclosures made of your medical information (“accounting of disclosures”). In some instances, the accounting may be limited by time and may exclude disclosures made for treatment, payment or health care operations.

Request Restrictions. You may request a reasonable restriction on the uses or disclosures of your medical information. However, we are not required to agree to your request. If you pay for your services, in full, using your personal funds, you can ask that the information regarding the service not be disclosed to a third-party payer since no claim is being made against the third-party payer.

Request Alternate Communications. You may request that we communicate with you about medical matters in a confidential manner or at a specific location. For example, you may ask that we only contact you via mail to a post office box.

Paper Copy of This Notice. You may request a paper copy of this notice at any time by contacting Healing Palms Healthcare LLC or Healing Palms Healthcare LLC’s Privacy Officer. You may obtain an electronic copy of this notice at our website, www.continuityproviders.com

To exercise any of these rights you must: submit your request in writing to Healing Palms Healthcare LLC or Healing Palms Healthcare LLC’s Privacy Officer. Your request should include a reason for your request and, if applicable, the action you want Healing Palms Healthcare LLC to take. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We will notify you of the cost involved and you may choose to change or take back your request at that time before any costs are incurred.

BREACH NOTIFICATION REQUIREMENTS: Healing Palms Healthcare LLC is required to notify you if unsecured PHI is acquired, accessed, used and/or disclosed by an unauthorized party. Notification must occur without unreasonable delay and in no case later than 60 days of the event.

QUESTIONS/GRIEVANCES:

If you want further information about matters covered by this notice, are concerned that your privacy rights may have been violated, or disagree with a decision made about access to your personal and health information, you may contact Healing Palms Healthcare LLC’s Privacy Officer by U.S. mail, fax, phone or email at: Healing palm healthcare LLC, Attention: Privacy Officer, 11175 Azusa Court, Rancho Cucamonga, California 91730, United States; Tel: 800-988-8764; E-mail: jude@healingpalmshealthcare.com

You may also submit a grievance/complaint to the U.S. Department of Health & Human Services, 200 Independence Ave., SW, Washington, DC 20201, Phone: 202.619.0257, Toll Free: 877.696.6775

Healing Palms Healthcare LLC will not retaliate and you will not be penalized in any way if you choose to file a grievance complaint with us or with the U.S. Department of Health and Human Services.