PANGEA MEDICAL, LLC

NOTICE OF PRIVACY PRACTICES

EFFECTIVE DATE: [NOVEMBER 29, 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.

 

OUR PLEDGE REGARDING MEDICAL INFORMATION

 

We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.  This Notice applies to the medical and health records that are created or received by Pangea Medical, LLC (“Pangea”).  The term “medical” in this Notice means information about your physical or mental condition which makes you eligible for our services, or which arises while we are providing support to you.  For example, this may include psychological tests, psychiatric assessments, medical or social assessments, or physical exams.

 

This Notice will tell you about the ways in which we may use and disclose medical information about you and provides examples of uses and disclosures.  It also provides examples of when we are required by law to disclose your information.

 

This Notice also explains your rights (and limits on those rights) to:

  • Have access to and a copy of your medical information;
  • Request changes to your medical information;
  • Request limits on disclosing your medical information;
  • Request that a different phone number or address be used for communication; and
  • Request a listing of disclosures other than for treatment, payment, or health care operations or pursuant to an authorization by you.

 

Our duties:

  • We are required by law to maintain the privacy of your medical information and to provide you with this Notice of our legal duties and privacy practices regarding your medical information.
  • We are required to notify you if your medical information that is not secured through encryption or destruction is breached.
  • We are required to follow the terms of this Notice.
  • This Notice is posted at the Pangea office. We may change the terms of this Notice and the revised Notice will apply to all medical information in our possession.  If we revise this Notice, a copy will be posted at the Pangea office and a copy may be requested from the Pangea Privacy Officer either at the Pangea office or by calling [224-470-1487].

 

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

 

For each category of uses or disclosures of medical information, we will explain what we mean and give some examples.  All of the ways we are permitted to use and disclose your medical information will fall within one of the categories.

 

Treatment:  We may use and disclose medical information about you to coordinate, manage and provide you with supports or services.  For example, your support team members will internally discuss your medical information in order to develop and carry out a plan for your services.  Also, different departments of Pangea may share medical information about you in order to coordinate the different things you need, such as prescriptions, medical tests, special dietary needs, respite care, personal assistance, day programs, etc.  We also may disclose medical information about you to physicians and other health care professionals to obtain physicians orders to provide therapy, consult about treatment alternatives, order adaptive equipment, etc.  Additionally, as a member of the Department of Mental Health’s Organized Health Care Arrangement, we may share medical information about you with other members of that arrangement for the purpose of treatment, payment or health care operations, as described later in this Notice.

 

Payment:  We may use and disclose medical information about you so that the supports you receive by Pangea may be billed to and payment may be collected from you, an insurance company or a third party.  For example, we may need to provide your insurance plan information about habilitation supports you received at Pangea so your insurance plan, or any applicable Medicaid or Medicare funds, will pay us for the services.  We may also tell your insurance plan or other payer about a service you are going to receive in order to obtain prior approval or to determine whether the service is covered.  In addition, in order to correctly determine your ability to pay for services, we may disclose your information to the Social Security Administration, the Division of Employment Security, or the Department of Social Services.

 

Health Care Operations:  We may use and disclose medical information about you for health care operations.  Health care operations include review of the care you receive for quality assessment, educational, business planning and compliance plan purposes.  For example, we may use medical information for quality improvement to review our planning and supports, and to evaluate the performance of our staff in providing supports to you.  We may also combine information about many individuals Pangea supports to decide what additional supports Pangea should offer, what supports are not needed, and whether certain new supports are effective.  It may also be necessary to obtain or exchange your information with the Department of Elementary and Secondary Education, the Department of Social Services, Vocational Rehabilitation, the Office of State Courts Administrator, Health and Senior Services or other Missouri state agencies or interagency initiatives; however any such use or disclosure will only occur in accordance with applicable law.  Or, we may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning the identity of specific individuals.  This may be in the form of providing information to our regional advisory councils or state advisory councils or planning councils.

 

Appointment Reminders:  We may use and disclose medical information to contact you as a reminder that you have an appointment for services with Pangea.

 

Treatment Alternatives and Health-Related Benefits and Services:  We may use and disclose medical information to tell you about or recommend possible health-related benefits, services, treatment options, or alternatives that may be of interest to you.

 

Required by Law:   We will disclose medical information about you when required to do so by federal, state or local law.

 

To Prevent a Serious Threat to Health or Safety:  We may disclose medical information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.

 

Research:  You will not be the subject of research without your prior written and informed consent.  Unless otherwise described in the consent, your identity and your health information will remain private during and after the research.  All research projects must comply with state and federal regulations.

 

Individuals Involved in Your Care or Payment for Your Care:  Unless you object, we may release medical information about you to a friend, family member, or other who is involved in your medical care.  This would include persons named in any durable health care power of attorney or similar document provided to us.  We may also give information to someone who helps pay for your care.  In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

 

SPECIAL SITUATIONS

 

Public Health Purposes:  We may disclose medical information about you for public health activities.  These activities generally include the following:  to prevent or control disease, injury or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe an individual 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.

 

Health Oversight Activities:  We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, 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.

 

Judicial and Administrative Proceedings:  We may be required to disclose your medical information to a court or for an administrative proceeding.

 

Law Enforcement Activities:  We may release medical information if asked to do so by a law enforcement official; however, if the material is protected by 42 CFR Part 2 (a federal law protecting the confidentiality of drug and alcohol abuse treatment records), a court order is required.  We may also release limited medical information to law enforcement in the following situations: 1) about an individual who may be a victim of a crime if, under certain limited circumstances, we are unable to obtain the individual’s agreement; 2) about a death we believe may be the result of criminal conduct; 3) about criminal conduct at Pangea; 4) about an individual where an individual commits or threatens to commit a crime on the premises or against Pangea staff (in which case we may release the individual’s name, address, and last known whereabouts); 5) in emergency circumstances, to report a crime, the location of the crime or victims, and the identity, description and/or location of the person who committed the crime; and 6) when the individual is a forensic client and we are required to share with law enforcement by Missouri statute.

 

In Emergency Circumstances:  We may disclose medical information about you to provide care to you in an emergency.

 

Deceased Individual:  We may release medical information to a coroner or medical examiner about you for purposes of identifying your body or to determine the cause of death.  We may also release medical information about you to funeral directors as necessary to carry out their duties.

 

Military and Veterans:  If you are a member of the armed forces, we may release medical information about you as required by military command authorities.  We may also release medical information about foreign military personnel to the appropriate foreign military authority.

 

Inmates:  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official if the release is necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.

 

Protective Services for the President and Others:  We may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President and other authorized persons or foreign heads of state.

 

Organ and Tissue Donation:  If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

 

Workers’ Compensation:  When disclosure is necessary to comply with Workers’ Compensation laws or purposes, we may release medical information about you for Workers’ Compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

 

National Security and Intelligence Activities:  We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

 

Disaster Relief:  We may disclose medical information about you to public or private agencies for disaster relief purposes.

 

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

 

You have the following rights regarding medical information we maintain about you:

 

Right to Inspect and Copy:  You have the right to inspect and copy your medical information with the exception of psychotherapy notes and under certain circumstances such as information compiled in anticipation of litigation or if providing you with such access will endanger your life or physical safety.  To the extent feasible, the access or a copy of your medical information will be provided to you in the form or format that you request, including an electronic form or format if we maintain your medical information electronically.  To inspect and copy your medical information, you must submit your request in writing on the form provided by Pangea.  To request a form, contact Pangea’s Privacy Officer at [224-470-1487].  If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.  We may deny your request to inspect and copy in certain limited circumstances.  If you are denied access to your medical information because of a threat or harm issue, you may request that the denial be reviewed.  Another licensed health care professional chosen by Pangea will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

 

Right to Request an Amendment:  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for Pangea.  To request an amendment, your request must be made in writing on the form provided by Pangea.  To request a form, contact Pangea’s Privacy Officer at [224-470-1487].  You must provide a reason to support your request for an amendment.  We may deny your request if it is not in writing or if it does not include a reason supporting the request.  In addition, we may deny your request if you ask us to amend information that:

 

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for Pangea;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

 

Right to an Accounting of Disclosures:  You have the right to request an “accounting of disclosures” for the six (6) years prior to your request for the accounting.  This is a list of the disclosures made by Pangea of your medical information.  You will not receive an accounting of disclosures for treatment, payment, and healthcare operations; disclosures made to you; disclosures made pursuant to an authorization; incidental disclosures; disclosures of information for notification purposes, for disaster relief purposes, and to persons involved in your care; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials having custody of you; and disclosures made as part of a limited data set.  You may receive one (1) free accounting during a twelve (12) month period.  If you request more than one (1) accounting you will be charged a fee.  We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

 

To request this list or accounting of disclosures, you must submit your request in writing on the form provided by Pangea.  To request a form, contact Pangea’s Privacy Officer at [224-470-1487].

 

Right to Request Restrictions:  You have the right to request a restriction on how medical information about you is used and disclosed.  To request a restriction, you must submit your request in writing, on the form provided by Pangea.  To request a form, contact Pangea’s Privacy Officer at [224-470-1487].  We are not required to agree to your request, except if you have paid for services out-of-pocket in full and ask us not to disclose your medical information related solely to those services to your health plan for payment or health care operations purposes.  .

 

Right to Confidential Communications:  You have the right to request that communications we make with you be made at an alternative address or phone number.  To request confidential communications, contact Pangea’s Privacy Officer at [224-470-1487].

 

Right to a Paper Copy of This Notice:  You have the right to a paper copy of this Notice.  To obtain a paper copy of this Notice, request a copy from Pangea’s Privacy Officer at [224-470-1487].

 

CHANGES TO THIS NOTICE

 

We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice in the Pangea office.  A particular Notice’s effective date is on the first page under the heading.

 

COMPLAINTS

 

If you believe your privacy rights have been violated, you may file a complaint with Pangea.  All complaints must be submitted in writing on the form provided by Pangea.  To obtain a form, contact Pangea’s Privacy Officer at [224-470-1487].  You also may file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601, 800.368.1019.

 

You will not be penalized or retaliated against for filing a complaint.

 

OTHER USES OR DISCLOSURES OF MEDICAL INFORMATION

 

Other uses and disclosures of medical information not covered in this Notice will be made only with your written authorization, including (1) most uses and disclosures of psychotherapy notes; (2) uses and disclosures of your medical information for marketing purposes; and (3) disclosures that constitute the sale of your medical information.  If you provide us with written authorization to use or disclose medical information about you, you can change your mind and revoke your authorization at any time, as long as it is in writing.  If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization and we are required to retain our records of the support we provided to you.

 

If you have any questions about this Notice, please contact Pangea’s Privacy Officer at [224-470-1487].