[45 CFR 164.520]
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.
TC Time LLC is required by state and federal law to maintain the privacy of your Protected Health Information (“PHI”) and to provide you with notice of our legal duties and privacy practices with respect to PHI. PHI includes the information and records we have about your health, and the health care services you receive in our facility. PHI is information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose PHI to carry out treatment, payment, or other health care services and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. TC Time LLC professionals, employees, students, volunteers and business associates are all required to follow our privacy practices in caring for our patients. If you suspect that this policy has been violated, please bring the incident to the attention of our executive staff.
Uses and Disclosures of PHI: TC Time LLC healthcare providers may use or disclose your PHI for the purposes of treatment, payment, and health care services, described in more detail below, without obtaining written authorization from you. The examples provided are not exhaustive; however, all uses and disclosures for treatment, payment or health care operations will fall into one of these categories.
We may use and disclose PHI in the course of providing, coordinating or managing your health care treatment and any related services or to provide you with medical or physical treatment or services, including the disclosure of PHI for treatment activities of another health care provider. For example, we may provide your physician or other health care provider with copies of your evaluations, progress notes, or other records that will help treat you. We may disclose your information to individuals outside of our facility to coordinate your medical care including your family members and other health care providers that are assisting in your medical treatment.
Payment: We may use and disclose your PHI to bill and collect payment for the health care services provided to you. This may include requests from your health insurance plan for purposes of verifying eligibility or coverage for insurance benefits, reviewing treatments for medical necessity, and performing utilization reviews. Medical bill submitted to an insurance company may include your name, diagnosis, and details of the treatment you are receiving for reimbursement. We may also disclose PHI to our business associates, such as billing companies, and claims processing companies.
Health Care Operations: We may use and disclose PHI as part of their operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive
and the performance of our staff in caring for you. Other activities include licensing and credentialing, training, learning purposes, compliance and risk management activities, planning and development and administration. For quality assessment, we may use your health record to monitor the performance of the staff providing treatment to you. We may disclose your health information to third-party business associates, as necessary, in order for the third party to provide a service to us. A written contract outlining the terms that will protect the privacy of your PHI will be obtained from each business associate prior to the use or disclosure of your PHI.
Appointment Reminders, Follow-Up Care and Treatment Alternatives: We may use and disclose your PHI to contact you to remind you of your appointments and to provide you with information regarding treatment alternatives or other health-related benefits and services that may be of interest to you. Please notify our patient service representative if you would like to request that your information not be used to contact you for these purposes. If you have provided your email address, you may elect to receive this information via email.
Fundraisers: We may use and disclose your demographic information and the dates that you received services to contact you as part of a fundraising effort. If you would like to request that you not be contacted for fundraising purposes, please contact our patient service representative. You have a right to opt out of receiving such fundraising communications and in the event you are contacted for fundraising, you will be given the opportunity to opt out.
AsRequiredbyLawandLawEnforcement: We will use and disclose your PHI when required to do so by federal, state or local law without your authorization. We may disclose PHI when ordered to in a judicial, discovery request, court order or other legal process. We may disclose PHI for law enforcement purposes to identify or locate a suspect, fugitive, material witness or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, its location or victims, or the identity, description or location of a person who committed a crime and for legal processes for emergency circumstances in accordance with local, state, and federal laws.
Abuse or Neglect: As mandated reporters under Georgia’s law, we may disclose your PHI to an authorized government authority if we reasonably believe you are the victim of abuse or neglect. We will only disclose information we believe is necessary to prevent serious harm and only to the extent allowed or required by law.
For Public Health Activity: We may disclose your PHI to public health agencies for activities with the purpose of preventing or controlling disease, injury or disability and reporting suspected abuse or neglect, non-accidental injuries, domestic violence, and reaction to treatment or medication, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition in accordance with local, state, and federal laws.
For Health Oversight Activities: We may disclose certain information to the government for authorized oversight activities including inspections, audits, licensure and other investigations of our providers or related matters. Authorized oversight agencies include, but are not limited to, the Georgia Department of Community Health (“DCH”) and any of its Divisions including Health
Facility Regulations (“HFR”), the Georgia Department of Public Health (“DPH”), the United States Department of Health & Human Services (“HHS”), HHS Office of Inspector General (“OIG”), Centers for Medicare & Medicaid Services (“CMS”), Medicare Fee for Service Recovery Audit Contractor (“RAC”), or other agencies that oversee the health care system, government benefit programs, regulatory agencies and civil rights laws to perform such activities as audits, investigations, inspections, and licensure.
Coroners, Funeral Directors and Organ Donation: We may disclose PHI to coroners, medical examiners and funeral directors for the purpose of identifying a decedent, determining a cause of death or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
Research: As federal regulations permit use of PHI in medical research, we may disclose your PHI to a researcher when their research has been approved by the DPH’s Institutional Review Board (“IRB”) or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI. We will ask your permission if the researcher will have access to your identifiable information such as your name, address, or other information that reveals your identity.
SpecializedGovernmentFunctions(MilitaryActivityandNationalSecurity):We may use or disclose PHI if you are military personnel or a veteran as required by military command authorities, for determining benefits through the Department of Veteran Affairs (the “VA”) and about foreign military personnel to the appropriate foreign military authority. We may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state in accordance with local, state, and federal laws.
Workers’ Compensation: We may use and disclose PHI to comply with workers’ compensation or other similar laws that provide benefits for work-related injuries or illnesses.
Others Involved in Your Health Care or Payment for Your Care: Unless you object, we may disclose your PHI to a family member, relative, close friend or any other person you identify as involved in your health care or payment for your health care. We may use or disclose information to family members or others involved in the care of deceased individuals. We may also notify those people about your location or condition.
Other Uses and Disclosures: Uses and disclosure of your PHI will be made only following your written authorization for purposes other than as described above or as permitted or required by law. You may revoke an authorization in writing at any time and we will no longer use or disclose your PHI as indicated in the authorization except to the extent that we have already acted in accordance with the authorization. We may not use and disclose your PHI for marketing purposes except in limited circumstances as authorized by law or unless you have given us written authorization. We will not disclose psychotherapy notes except in limited circumstances either with your written authorization or as applicable law permits. We will not sell your PHI unless we have your written authorization or applicable law permits.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Right to Access Record, Inspect and Copy: You have the right to inspect and obtain a copy of your PHI that we use to make decisions about you, for so long as we maintain the information. If we do not maintain records of the health information you requested about yourself, but we know where the information is maintained, we will inform you about where to direct your request. You must submit a written request to inspect and/or receive a copy of your records. As permitted by federal or state law, we may charge you a reasonable fee to fulfill your request. We may deny your request to inspect and/or copy your records in certain limited circumstances under state and federal law. If you are denied access to your records, you may request that the denial be reviewed. Your requested review will be conducted by someone other than the person who denied your request.
RighttoRequestaRestriction:You have the right to request that we not use or disclose any part of your PHI for treatment, payment or health care operations. You also have the right to request that any part of your PHI not be disclosed to family, relatives or friends who may be involved in your care or payment for your care or for notification purposes as described in this Notice of Privacy Practices. We are not required to agree to a requested restriction except we must agree to a requested restriction of disclosure regarding your PHI to a health plan for payment purposes if the following conditions are met: (1) you have paid in full in advance for the associated treatment or services, (2) disclosure is not otherwise required by law and (3) you have made this request for restriction in writing when the services are performed. If we do agree to the requested restriction, we shall honor that agreement, unless the information is needed to provide emergency treatment. You may request a restriction by contacting our executive officer or patient service representative.
Right to Request to Receive Confidential Communication: You have the right to request that we send you confidential communications about medical matters through alternative means or at an alternative location such as using your home address instead of work address. We will accommodate reasonable requests regarding confidential communications as requested. To make a request of this nature, please contact the executive officer or patient service representative.
Right to Amend: You have the right to request an amendment of your PHI if you feel that it contains incorrect or incomplete information. To request an amendment, you must send a written request to our executive officer or patient service representative, including a reason that supports your request. We may deny your request for amendment if you ask us to amend information that:
(i) not created by the entity; (ii) that is not part of the records the entity maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, we will give you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and the entity’s denial attached; and (iii) complain about the denial.
Right to Receive an Accounting of Disclosure: You have the right to receive an accounting of the disclosures we have made of your PHI for purposes other than treatment, payment or health care operations. An accounting of disclosures made through an electronic health record will also
account for disclosures for treatment, payment and health care operations purposes during the three years prior to your request, at such time as the secretary of the U.S. Department of Health and Human Services provides regulations addressing this requirement. The list will not include disclosures (i) for which you have provided a written authorization; (ii) for treatment, payment and health care operations; (iii) made to you; (iv) for a Peachtree Physical Therapy provider’s patient directory or to persons involved in your health care; (v) for national security or intelligence purposes; (vi) to correctional institutions or law enforcement officials; or (vii) of a limited data set. To obtain this account, you must submit your request in writing to our executive officer or patient service representative stating the time period for which you want an accounting and not including dates more than six years prior to the request. The right to receive an accounting is subject to certain exceptions, restrictions, and limitations. The entity will provide the list to you at no charge, but extra charges may be applied in case of making more than one request in a year. Please contact our executive officer or patient service representative for more information.
RighttoObtainaPaperCopyofThisNotice:You have the right to request a paper copy of this notice, even if you have agreed to accept this notice electronically. You may ask us to give you a copy of this notice at any time. Request a paper copy of this notice by contacting our executive officer or patient service representative as described below.
RighttoBeNotifiedofaBreach:We are required to notify affected individuals in the event there is a breach of unsecured protected health information.
Changes to This Notice: We reserve the right to revise the terms of this notice and to make the new provisions effective for the health information we maintain at the time of the change in accordance with law, as well as information we will obtain about you in the future.
Complaints: If you believe your privacy rights with respect to your PHI have been violated you have the right to contact the executive officer or patient service representative as described below and submit a written complaint. We will not penalize you or retaliate against you for filing a complaint regarding their privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services.
If you seek to file a complaint with us directly, you may submit your complaint by contacting our staff as described below for further information about the complaint process.
TC Time, LLC
1300 Peachtree Industrial Blvd. Ste 4108
Suwanee, Georgia 30024
Email Address: firstname.lastname@example.org
Telephone number: 470-238-3683
Fax number: 470-238-3816
This notice was published and became effective on Effective as of September 01, 2020