I. CONTACT PERSON. If you have any questions about this
Notice of Privacy Practices (Notice), please contact us through
one of the methods listed at the end of this Notice.
II. EFFECTIVE DATE OF THIS NOTICE. The original effective
date of this Notice was April 26, 2003. The most recent revision
date is at the end.
III. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR
PROTECTED HEALTH INFORMATION (PHI). We are required by
law to maintain the privacy of your personal information. This
medical information is called protected health information or
(PHI) for short. PHI includes information that can be used to
identify you that we have created or received about your past,
present, or future health or medical condition, the provision
of health care to you, or the payment of this health care. We
need access to your medical records to provide you with health
care and to comply with certain legal requirements. This Notice
applies to all of the records of the care and services you receive
from us, whether made by our employees or your physician.
This Notice will tell you about the ways in which we may use
and disclose PHI about you and describes your rights and
certain obligations we have regarding the use and disclosure of
However, we reserve the right to change the terms of this
Notice and our Privacy Policies and Procedures at any time. Any
changes will apply to the PHI we already have. When we make
a significant change in our privacy practices, we will change
this notice and post when applicable or provide you a copy of
the revised notice. You can also request a copy of this Notice
from us at any time by contacting us using any of the methods
described on the last page of this notice.
IV. OUR DUTIES. We are required by law to:
- make sure that PHI that identifies you is kept private;
- give you this Notice of our privacy practices with respect
to your PHI;
- disclose information on HIV, mental health, and/or
communicable diseases only as permitted under federal
and state law; and
- follow the terms of this Notice as long as it is currently in
effect. If we revise this Notice, we will follow the terms of
the revised Notice.
V. HOW WE MAY USE AND DISCLOSE YOUR PHI. The
following categories (listed in bold-face print) describe
different ways that we use and disclose your PHI.
Disclosures of PHI may be provided in various media, including electronically. For each category of uses or
disclosures we will explain what we mean and give you
some examples. Not every use or disclosure in a category
will be listed. However, all of the ways we are permitted
to use and disclose information about you will fall within
one of the bold-face print categories. Also, not all of the
categories may apply to the health care service you are
seeking. For example, if your employer is paying for a
service (pre-employment or biometric screening), then we
would not release your information to the insurance carrier
A. For Treatment. We may disclose your PHI to
physicians, nurses, case managers, and other health care
personnel who provide you with health care services or are
involved in your care. We may use and disclose your PHI
to provide and coordinate the treatment, medications and
services you receive including dispensing of prescription
medications when applicable. For example, if you're
being treated for a knee injury, we may disclose your PHI
regarding this injury to a physical therapist or radiologist,
or to medical equipment suppliers or case managers.
B. To Obtain Payment for Treatment. We may use
and disclose your PHI in order to bill and collect payment
for the treatment and services provided to you. For
example, we may provide portions of your PHI to our
billing department and your health plan to get paid for
the health care services we provided to you. We may also
provide your PHI to our Business Associates, such as billing
companies and others that process our health care claims.
C. For Health Care Operations. We may disclose your
PHI in order to operate our facilities. For example, we
may use your PHI to evaluate the quality of health care
services that you received, for utilization management
activities, or to evaluate the performance of the health
care professionals who provided the health care services
to you. We may also provide your PHI to our accountants,
attorneys, consultants, and others in order to make sure
we are complying with the laws that affect us.
D. To Business Associates for Treatment, Payment,
and Health Care Operations. We may disclose PHI about
you to one of our Business Associates in order to carry
out treatment, payment, or health care operations. For
example, we may disclose PHI about you to a company
who bills insurance companies on our behalf so that
company can help us obtain payment for the health care
services we provide.
E. Individuals Involved in Your Care or Payment for
Your Care. We may release PHI about you to a family
member, other relative, or close personal friend who is
directly involved in your medical care if the PHI released is relevant to such person's involvement with your care. We
also may release information to someone who helps pay
for your care. In addition, we may disclose PHI about you
to an entity assisting in a disaster relief effort so that your
family can be notified about your location and general
We may release health or health-related information
about you to your employer if we provide services at
their request. If services are provided at your employer's
location, please be aware that due to the nature of shared
facilities and services, your employer may have access
to your records. For example, this may occur with shared
staff, storage, or technology.
F. Appointment Reminders. We may use and disclose
PHI to contact you as a reminder that you have an
appointment for treatment or health care if you have not
opted out of such reminders.
G. Treatment Alternatives. We may use and disclose
PHI to give you information about treatment options or
alternatives if you have not opted out of such reminders.
We may contact you regarding compliance programs such
as drug recommendations, drug utilization review, product
recalls and therapeutic substitutions.
H. Health-Related Benefits and Services. We may use
and disclose PHI to tell you about health-related benefits
or services that may be of interest to you if you have not
opted out of such reminders.
I. Workers' Compensation.* We may release PHI about
you for workers' compensation or similar programs. These
programs provide benefits for work-related injuries or
J. Special Situations.*
1. As Required By Law.* We will disclose PHI about
you when required to do so by federal, state, or local law,
such as the Occupational Safety and Health Act (OSHA),
Federal Drug Administration (FDA), or Department of
2. Public Health Activities.* We may disclose PHI about
you for public health activities. Public health activities
a. preventing or controlling disease, injury or disability;
b. reporting births and deaths;
c . reporting child abuse or neglect;
d. reporting reactions to medications or problems with
e. notifying people of recalls of products;
f. notifying a person who may have been exposed
to a disease or may be at risk for contracting or
spreading a disease;
g. notifying the appropriate government authority if
we believe a patient has been the victim of abuse,
neglect or domestic violence. We will only make
this disclosure if you agree or when required or
authorized by law.
3. Health Oversight Activities.* We may disclose PHI to
a health oversight agency for activities authorized by law
such as audits, investigations, inspections, and licensure.
These activities are necessary for the government to
monitor the health care system, government programs,
and compliance with civil rights laws.
4. Lawsuits and Disputes.* If you are involved in a
lawsuit or a dispute, we may disclose PHI about you under
a court or administrative order. We may also disclose PHI
about you in response to a subpoena, discovery request, or
other lawful process by someone else in the dispute.
5. Law Enforcement.* We may release PHI if asked to do
so by a law enforcement official:
a. in response to a court order, subpoena, warrant,
summons or similar process;
b. to identify or locate a suspect, fugitive, material
witness, or missing person, but only if limited
information (e.g., name and address, date and
place of birth, social security number, blood type,
RH factor, injury, date and time of treatment, and
details of death) is disclosed;
c. about the victim of a crime if, under certain limited
circumstances, we are unable to obtain the person's
d. about a death we believe may be the result of
e. about criminal conduct we believed occurred at our
f. in emergency circumstances to report a crime; the
location of the crime or victims; or the identity,
description or location of the person who committed
6. Coroners, Medical Examiners and Funeral Directors.*
We may release PHI about patients to a coroner or
medical examiner to identify a deceased person or to
determine the cause of death or to funeral directors to
carry out their duties.
7. Organ and Tissue Donation.* We may release PHI to
organizations that handle organ procurement or organ,
eye or tissue transplantation or to an organ donation bank
to facilitate organ or tissue donation.
8. Research.* Under certain circumstances, we may
use and disclose PHI about you for research purposes.
For example, a research project may involve comparing
the health and recovery of all patients who received one
medication to those who received another for the same
condition. All research projects are subject to a special
approval process which requires an evaluation of the
proposed research project and its use of PHI, and balances
these research needs with our patients' need for privacy.
Before we use or disclose PHI for research, the project
generally will have been approved through this special
approval process. However, this approval process is not
required when we allow PHI about you to be reviewed
by people who are preparing a research project and who
want to look at information about patients with specific
medical needs, so long as the PHI does not leave our
9. To Avert a Serious Threat to Health or Safety.* We may
use and disclose PHI when necessary to prevent a serious
threat to your health and safety or the health and safety
of the public or another person. Any disclosure, however,
would only be to someone who is able to help prevent the
10. Armed Forces and Foreign Military Personnel.* If you
are a member of the Armed Forces, we may release PHI as
required by military command authorities or about foreign
military personnel to the appropriate foreign military
11. National Security and Intelligence Activities.* We
may release PHI about you to authorized federal officials
for intelligence, counterintelligence, and other national
security activities authorized by law.
12. Protective Services for the President and Others.*
We may disclose PHI about you to authorize federal
officials so they may provide protection to the President,
other authorized persons or foreign heads of state, or to
conduct special investigations.
13. Inmates.* If you are an inmate of a correctional
institution or under the custody of a law enforcement
official, we may release PHI about you to the correctional
institution or law enforcement official. This release would
be necessary, for example, for the institution to provide
you with health care; to protect your health and safety
or the health and safety of others; or for the safety and
security of the correctional institution.
14. Food and Drug Administration (FDA) We may use
and disclose to the Food and Drug Administration (FDA), or
person under the jurisdiction of the FDA, protected health
information relative to adverse events with respect to
drugs, foods, supplements, products, and product defects,
or post marketing surveillance information to enable
product recalls, repairs, or replacement.
K. Incidental Uses and Disclosures.* Uses and
disclosures that occur incidentally with a use or disclosure
described in this Notice are acceptable provided there are
reasonable safeguards in place to limit such incidental
uses and disclosures.
*In New Mexico and Pennsylvania, uses and disclosures
other than those marked with an asterisk may require
your written authorization.
VI. WHAT DO WE DO WITH YOUR INFORMATION WHEN
YOU ARE NO LONGER A PATIENT OR YOU DO NOT OBTAIN
SERVICES THROUGH US? Your information may continue
to be used for purposes described in this notice when you
do not obtain services through us. After the required legal
retention period, we destroy the information following
strict procedures to maintain the confidentiality.
*This right applies only to our Massachusetts residents in
accordance with state regulations.
VII. YOUR RIGHTS REGARDING YOUR PHI.
A. The Right to Request Limits on Uses and Disclosures
of Your PHI. You have the right to ask that we limit how
we use and disclose your PHI. We will consider your
request but are not legally required to approve it. If we
approve your request, we will put any limits in writing and
follow them except in emergency situations. You may not
limit the uses and disclosures that we are legally required
or allowed to make.
You have the right to request a restriction on disclosures
of medical information to a health plan for purposes of
carrying out payment or health care operations. We must
comply as long as it is not for purposes of carrying out
treatment; and the PHI pertains only to a health care
service for which we have been paid out of pocket in full
without the application of insurance benefits or discounts.
If the payment is not honored, then we do not need to
comply with the request if we need to seek payment.
B. The Right to Choose How We Send PHI to You. You
have the right to ask that we send information to you to
an alternate address or via an alternate method. We must
agree to your request so long as we can easily provide it in
the format you requested.
C. The Right to See and Get Copies of Your PHI. In
most cases, you have the right to look at or get copies of
your PHI that we have, but you must make the request
in writing. If we do not have your PHI, but we know who
does, we will tell you how to get it. In certain situations,
we may deny your request. If we do, we will tell you in
writing our reasons for the denial and explain your right
to have the denial reviewed. If you request copies of
your PHI, there may be a per page charge. Instead of
providing the PHI you requested, we may provide you with
a summary or explanation of the PHI as long as you agree
to that and to any additional costs in advance.
D. The Right to Get a List of the Disclosures We Have
Made. You have the right to get a list of instances in which
we have disclosed your PHI in the past six (6) years. The list
will include the date of the disclosure(s), to whom PHI was
disclosed, a description of the information disclosed, and
the reason for the disclosure. The list will not include uses or
disclosures that were made for the purposes of treatment,
payment or health care operations, uses or disclosures
that you authorized, or disclosures made directly to you
or to your family. The list also will not include uses and
disclosures made for national security purposes, or to
corrections or law enforcement personnel. Your request
must state a time period that may not be longer than six
(6) years prior, but may certainly be less than six (6) years.
E. The Right to Correct or Update Your PHI. If you feel
that the PHI we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the
right to request an amendment of the existing information
or to add the missing information. You must provide the
request and your reason for the request in writing. If we
approve your request, we will make the change to your
PHI, tell you that we have done it, and tell others that
need to know about the change to your PHI. We may deny
your request if the PHI is: (i) correct and complete, (ii) not
created by us, (iii) not allowed to be disclosed, or (iv) not
part of our records. Our written denial will state the reasons
for the denial and explain your right to file a written
statement of disagreement with the denial. If you do not
file a statement of disagreement, you have the right to
request that your request and our denial be attached to all
future disclosures of your PHI.
F. The Right to Get This Notice. You have the right to get
a copy of this Notice in paper and by e-mail.
G. How Will My Information be Used for Purposes
Not Described in This Notice? In all situations other
than described in this notice, we will request your written
permission before using or disclosing your information.
You may revoke your permission at any time by notifying
us in writing. We will not disclose your information for
any reason not described in this notice without your
permission. The following uses and disclosures will require
1. Most uses and disclosures of psychotherapy notes
2. Marketing purposes
3. Sale of protected health information
H. What type of communications can I opt out of being
made to me? You can opt out at the address below
regarding the following communications:
a Appointment reminders.
b. Treatment alternatives or other health-related
benefits and services.
VIII. HOW TO REQUEST YOUR PRIVACY RIGHTS. If you
believe your privacy has been violated in any way, you
may file a complaint by contacting us as described below.
We are committed to responding to your rights request
in a timely manner. To request any of your privacy rights,
please contact us:
• Call us at 1-866-861-2762
• E-mail us at email@example.com
• Send your opt-out request to us in writing
Privacy Office 003/10911
101 E. Main Street
Louisville, KY 40202
You may also submit a written complaint to the U.S.
Department of Health and Human Services, Office for
Civil Rights (OCR). We will give you the appropriate OCR
regional address on request. You also have the option
to e-mail your complaint to OCRComplaint@hhs.gov. We
support your right to protect the privacy of your personal
and health information. We will not retaliate in any way
if you elect to file a complaint with us or with the U.S.
Department of Health and Human Services.
We will respond to all privacy requests and complaints.
It has always been our goal to ensure the protection
and integrity of your personal and health information.
Therefore, we will notify you of any potential situation
where your information would be used for reasons other
than what is listed above.
IX. What will happen if my private information is used of
disclosed inappropriately. You have the right to receive a
notice that a breach has resulted in your unsecured private
information being inappropriately used or disclosed. We
will notify you in a timely manner if such a breach occurs.
* RightSourceRx is a subsidiary of Humana. Humana will
respond to all privacy requests and complaints.
Date of Last Revision: July 2013