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.
This Notice describes how Oluwatoyin Ajayi Medical Practice, PC dba Cityblock Medical Practice (and Cityblock Health, Inc., when acting on behalf of Cityblock Medical Practice) may use and disclose health information about you (“Protected Health Information”) and how you can access this information. Please review it carefully.
We understand that your health information is personal and we are committed to protecting your privacy. In addition, we are required by law to maintain the privacy of your Protected Health Information, to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information, and to notify you in the event of a breach of your unsecured Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
In certain situations, which we will describe in Section III below, we must obtain your written authorization in order to use and/or disclose your Protected Health Information. However, unless the Protected Health Information is Highly Confidential Information (as defined in Section III.D below) and the applicable law regulating such information imposes special restrictions on us, we may use and disclose your Protected Health Information without your written authorization for the following purposes:
We use and disclose your Protected Health Information to provide treatment and other services to you to diagnose your illness or injury. We may use your information to direct or recommend alternative treatments, therapies, health care providers, or settings of care to you or to describe a health-related product or service. We may also disclose Protected Health Information to other providers involved in your treatment.
We may use and disclose your Protected Health Information to obtain payment for health care services that we provide to you--for example, disclosures to claim and obtain payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of your health care (“Your Payor”) to verify that Your Payor will pay for the health care. We may also disclose Protected Health Information to your other health care providers when such Protected Health Information is required for them to receive payment for services they render to you.
We may use and disclose your Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use Protected Health Information to evaluate the quality and competence of our physicians, health care professionals, and community health partners. We may disclose Protected Health Information to our Member Experience Manager in order to resolve any complaints you may have and ensure that you are satisfied with our services. We also may create and use de-identified information, where information is removed from your Protected Health Information so that you can’t be identified, as authorized by law.
We may use or disclose your Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure. If you are not present for or unavailable prior to a disclosure (e.g., when we receive a telephone call from a family member or other caregiver), we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information under such circumstances, we would disclose only information that is directly relevant to the person’s involvement with your care.
We may use and disclose your Protected Health Information when required to do so by any applicable federal, state or local law.
We may disclose your Protected Health Information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
We may disclose your Protected Health Information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.
We may disclose your Protected Health Information to an agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
We may disclose your Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
We may disclose your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.
We may disclose your Protected Health Information to a coroner or medical examiner as authorized by law.
We may disclose your Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
We may use and disclose your Protected Health Information for research purposes pursuant to a valid authorization from you or when an institutional review board or privacy board has waived the authorization requirement. Under certain circumstances, your Protected Health Information may be disclosed without your authorization to researchers preparing to conduct a research project, for research or decedents or as part of a data set that omits your name and other information that can directly identify you.
We may use or disclose your Protected Health Information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
We may use and disclose your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
We may disclose your Protected Health Information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
For any purpose other than the ones described above in Section II, we only use or disclose your Protected Health Information when you give us your written authorization.
We must obtain your written authorization prior to using your Protected Health Information for purposes that are marketing under the HIPAA privacy rules. For example, we will not accept any payments from other organizations or individuals in exchange for making communications to you about treatments, therapies, health care providers, settings of care, products or services unless you have given us your authorization to do so or the communication is permitted by law.
These marketing restrictions do not include face-to-face communication about products or services that may be of benefit to you, or about prescriptions you have already been prescribed.
We will not make any disclosure of Protected Health Information that is a sale of Protected Health Information without your written authorization.
We will not use or disclose psychotherapy notes about you without your authorization except for use by the mental health professional who created the notes to provide treatment to you, for our mental health training programs or to defend ourselves in a legal action or other proceeding brought by you.
Federal and state law requires special privacy protections for certain health information about you (“Highly Confidential Information”), including Alcohol and Drug Abuse Treatment Program records and other health information that is given special privacy protection under state or federal laws other than HIPAA. However, in order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization.
You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below.
If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your Protected Health Information, you may contact our Privacy Office. 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.
You may request restrictions on our use and disclosure of your Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction unless the request is to restrict our disclosure to a health plan for purposes of carrying out payment or health care operations, the disclosure is not required by law and the information pertains solely to a health care item or service for which you (or someone on your behalf other than the health plan) have paid us out of pocket in full. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.
You may request, and we will accommodate, any reasonable written request for you to receive your Protected Health Information by alternative means of communication or at alternative locations.
You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we may charge you a reasonable copy fee.
You have the right to request that we amend your Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
Upon request, you may obtain an accounting of certain disclosures of your Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.
Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.
This Notice is effective on July 1, 2018.
We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all your Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting room and on our Internet site at www.cityblock.com. You also may obtain any new notice by contacting the Privacy Office.
You may contact the Privacy Office at:
55 Washington St, Suite 552
Brooklyn, NY 11201
Telephone Number: (929) 367-0973