NOTICE OF PRIVACY PRACTICES

Effective Date of Latest Revision: April 1st, 2013

How Medical Information may be Used and Disclosed, and Your Access to Medication Information: OptiMindHealth will follow the terms of this Notice and may share health information for purposes of treatment, payment and health care operations as described in this Notice and as required under the Health Insurance Portability and Accountability Act of 1996. It also describes your rights as they relate to your protected health information (PHI). This Notice has been updated in accordance with the HIPAA Omnibus Rule and is effective March 26, 2013. It applies to all PHI as defined by federal regulations..

Understanding Your Health Record, Rights, and Information: A record of your visit is made each time you visit OptiMindHealth. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information may be used or disclosed to plan your care and treatment, communicate with other providers who contribute to your care, serve as a legal document, receive payment from you, your health plan or your health insurer, to improve the care we render and the outcomes we achieve, or to comply with state and federal laws that require us to disclose your PHI. Although your health record is the physical property of OptiMindHealth the information belongs to you. You have the right to request to access your health record, or to have an electronic copy of your medical record be given to you or transmitted to another individual or entity. OptiMindHealth may charge you a reasonable, cost-based fee for the labor and supplies associated with copying or transmitting the electronic PHI. You have a right to amend your health record which you believe is not correct or complete. OptiMindHealth is not required to agree to the amendment if you ask us to amend information that is in our opinion: (i) accurate and complete; (ii) not part of the PHI kept by or for OptiMindHealth; (iii) not part of the PHI which you would be permitted to inspect and copy; or (iv) not created by OptiMindHealth, unless the individual or entity that created the information is not available to amend the information. If we deny your request, you may submit a written statement of disagreement of reasonable length. Your statement of disagreement will be included in your medical record, but we may also include a rebuttal statement. You have the right to obtain a written accounting of certain non-routine disclosures of your PHI. We are not required to list certain disclosures, including (i) disclosures made for treatment, payment, and health care operations purposes, (ii) disclosures made with your authorization, (iii) disclosures made to create a limited data set, and (iv) disclosures made directly to you. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years prior to the date of your request. As we maintain your medical records in an EMR system, you may request that the accounting include disclosures for treatment, payment and health care operations for the three (3) years prior to the date of such request. You must submit your request in writing to the OptiMindHealth Support Manager. Your first request for a listing of PHI disclosure accounting within a 12-month period of your visit is free of charge, but OptiMindHealth will charge you for additional lists within the same 12-month period. OptiMindHealth will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. You have the right to have communications of your PHI by alternative means (e.g. e-mail) or at alternative locations (e.g. post office box). Your PHI will not be disclosed to others without your express written consent, except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). OptiMindHealth will comply with a request to restrict the disclosure of PHI to a health plan for purposes of carrying out payment or health care operations if the PHI pertains solely to a health care item or service for which we have been paid out of pocket in full. You also have the right to revoke your authorization to use or disclose PHI except to the extent that action has already been taken.

Our Responsibilities, and Making Inquiries: OptiMindHealth is required to maintain the privacy of your PHI, provide you with access to this notice as to our legal duties and privacy practices, abide by the terms of the notice currently in effect, notify you in writing if we are unable to agree to a requested restriction, accommodate reasonable requests regarding communication of PHI, and notify you in writing of a breach where your unsecured PHI has been accessed, acquired, used or disclosed to an unauthorized person. We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, such revised Notices will be made available to you. We will not use or disclose your PHI without your written authorization, except as described in this Notice. If have questions and would like additional information, you may contact the OptiMindHealth Support Manager, at 800 Boylston Street, 16th Floor, Boston, MA 02199, and at 617-507-1472 Ext 5. If you believe your privacy rights have been violated, you can file a written complaint with OptiMindHealth’s Support Manager, or with the Office for Civil Rights, U.S. Department of Health and Human Services.

Treatment, Health Care Operations, Payments: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your medical record and used to determine the course of treatment that should work best for you. To promote quality care,OptiMindHealthoperates an electronic system that keeps PHI about you.OptiMindHealth may also provide a subsequent healthcare provider with PHI about you (e.g., copies of various reports) that should assist him or her in treating you in the future.OptiMindHealthmay also disclose PHI about you to, and obtain your PHI from, electronic PHI networks in which community healthcare providers may participate to facilitate the provision of care to patients such as yourself. OptiMindHealthmay use a prescription hub which provides electronic access to your medication history. This will assist health care providers at OptiMindHealthin understanding what other medications may have been prescribed for you by other providers.A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, diagnosis, procedures, and supplies used.We may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.We may contract with third parties to perform functions or activities on behalf of, or certain services for, OptiMindHealththat involve the use or disclosure of PHI and disclose your PHI to our business associate so that they can perform the job we have asked them to do. We require the business associate to appropriately safeguard your information.We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.We may call your home or other designated location and leave a message on voice mail, in reference to any items that assist OptiMindHealthin carrying out Treatment, Payment and Health Care Operations, such as appointment reminders, insurance items and any call pertaining to your clinical care. We may mail to your home or other designated location any items that assist OptiMindHealthin carrying out Treatment, Payment and Health Care Operations, such as appointment reminders, patient satisfaction surveys and patient statements.

Other Required Communications: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, PHI relevant to that person’s involvement in your care or payment related to your care. When a family member(s) or a friend(s) accompany you into the exam room, or are engaged in a conference call with you in the room, it is considered implied consent that a disclosure of your PHI is acceptable.In the unfortunate event of your death, we may disclose your PHI to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties. We are permitted to disclose your PHI to your personal representative and your family members and others who were involved in the care or payment for your care prior to your death, unless inconsistent with any prior expressed preference that you provided to us. PHI excludes any information regarding a person who has been deceased for more than 50 years.We may contact you by mail, e-mail or text to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. However, we must obtain your prior written authorization for any marketing of products and services that are funded by third parties. You have the right to opt-out by notifying us in writing.

Health Oversight Activities, Legal Obligations, Public Health, and Law Enforcement Communications: We may release your PHI to government agencies authorized to conduct audits, investigations, and inspections of our facility. We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.We may disclose PHI for law enforcement purposes as required by law.If you are an inmate or you are detained by a law enforcement officer, we may disclose your PHI to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety at the place where you are confined.We may disclose your PHI if we are ordered to do so by law, or by a court that is handling a lawsuit or other dispute. We may also disclose your information in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure.