FORWARD NOTICE OF PRIVACY PRACTICES
Last Updated: 04/08/2019
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY FORWARD AND FORWARD AFFILIATED PROFESSIONAL ENTITIES AND CARE PROVIDERS THAT ARE INVOLVED IN YOUR CARE AND TREATMENT FOR THE PURPOSE OF PROVIDING HEALTH CARE SERVICES TO YOU, SUCH AS PHYSICIANS OR PHYSICIAN ORGANIZATIONS. THIS NOTICE ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
BY CLICKING “AGREE,” YOU ACKNOWLEDGE THAT YOU HAVE RECEIVED AND READ THIS NOTICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “AGREE” BUTTON ON YOUR BEHALF.
We use the term “medical information” in this notice to mean your protected health information, including demographic 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 and other information related to your health care that we maintain about you.
We are required by law to:
- Maintain the confidentiality of your medical information in accordance with applicable federal and/or state law;
- Comply with the terms of this notice, including any amendments; and
- Give you this notice of our legal duties and privacy practices with respect to medical information we maintain about you.
We reserve the right to change the terms of this notice at any time. We also reserve the right to make the changes apply to your medical information we already have. Before we make a material change to this notice, we will promptly post a new notice in a clear and prominent area and on our website. You can also request a copy of the new notice from any of our registration staff.
How may we use and disclose medical information?
We may use and disclose your medical information without your consent or authorization for the following purposes:
- Treatment. We may use and disclose your medical information to the physicians, nurses, and other health care personnel who provide, coordinate or manage your health care and any related services. For example, our doctors and staff may use and disclose your medical information with each other to provide treatment to you. We may also disclose your medical information to another health care provider (i.e., who is not part of Forward), including genetic or other laboratories who conduct testing upon samples you provide to us.
- Payment. We may use and disclose your medical information in order to bill and collect payment for the treatment and services provided to you. For instance, we may provide portions of your medical information to your health plan to get paid for the health care services we provided to you. We may also disclose your medical information to your health plan to permit it to make a determination of eligibility or coverage for insurance benefits, to review the services we provided to you for medical necessity, and to perform utilization review activities. We also disclose medical information about you to the responsible party of your account. If you are listed as a dependent on another person's insurance policy, financial information regarding medical care provided may be mailed to that responsible party. In addition, if you do not timely pay us for the health care services we provided to you, we may also disclose limited medical information to a collection agency. We may also disclose your medical information to other health care providers, health plans or health care clearinghouses for their payment activities. For example, we may provide your medical information to an ambulance/transportation company that provided services to you.
- Health Care Operations. We may use and disclose your medical information in order to support our business activities, such as quality assessment activities, employee review activities, and conducting or arranging for our other business activities. For example, we may use your medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also use your medical information to evaluate and improve services provided by our business associates, including GoForward Inc. In addition, we may use and disclose your medical information to other health care providers, health plans or health care clearinghouses for their limited health care operations, such as quality assessment activities, licensing and other health care compliance activities.
- Business Associates. We may disclose your medical information to our business associates that assist us in our delivery of health care and related services, including GoForward Inc., a technology company that provides technological and administrative support for Forward, including providing our patients with a technological platform through which patients can access our services and their medical records. Other business associates may include billing companies, lawyers, accountants and others. Before we disclose your medical information to our business associates, we will have a written contract with each of them that will require each of them to agree to maintain the privacy of your medical information.
- Uses and Disclosures Required by Law. We may use or disclose your medical information as required by law, but must limit such use or disclosure to relevant information and otherwise comply with applicable legal requirements.
- Public Health Activities. For example, we may use or disclose your medical information to public health authorities responsible for collecting information for purposes of preventing or controlling disease and certain disclosures related to regulatory activities of the Food and Drug Administration.
- Abuse, Neglect, or Domestic Violence. We may use or disclose your medical information in some instances if we reasonably believe that you are a victim of abuse, neglect, or domestic violence.
- Health Oversight Activities. We may use or disclose your medical information for certain health oversight activities, including, for example, inspections and licensure of health care facilities.
- Judicial and Administrative Proceedings. We may use or disclose your health information under some circumstances in response to a subpoena or order by a court or administrative tribunal.
- Law Enforcement Purposes. For example, we may use or disclose your medical information to law enforcement officials for identification of suspects or where a crime has been committed on our premises.
- Decedents. We may use or disclose medical information to coroners, medical examiners, and funeral directors.
- Serious Safety Threat. We may use or disclose your medical information where we believe it is necessary to prevent or lessen a serious threat to the safety of a person or the public.
- Specialized Government Functions. We may use or disclose your health information under some circumstances for specialized government functions, including those related to the armed forces, national security, and intelligence.
- Workers' Compensation: We may use or disclose your medical information in order to comply with laws related to workers' compensation and similar programs.
- Scheduling Appointments, Appointment Reminders and Health Related Benefits or Services. We may use and disclose your medical information to schedule appointments, give you appointment reminders, and give you information about treatment alternatives or other health care related services or benefits we offer.
- Personal Representatives. We may disclose your medical information to your personal representatives that are appointed by you or authorized by applicable law.
- Inmates. If you are an inmate of a correctional institutional or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. We may release such information for purposes that include (1) providing you with health care; (2) protecting your health and safety or the health and safety of others; or (3) protecting the safety and security of the correctional institution.
Uses and Disclosures for which You Have An Opportunity to Agree or Object:
- Individuals Involved in Your Care. We may disclose your medical information to a family member, friend or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity for you to agree or object may be given retroactively in emergency situations.
Your Authorization Is Needed for Other Uses and Disclosures
We will not use or disclose your medical information for purposes not described in this notice or as otherwise permitted by applicable law unless you give us written authorization to do so, including by clicking “Agree” with respect to any Patient Authorization for Use and Disclosure of Information we provide to you electronically. If you give us such written authorization, then, in most cases, you may revoke it in writing at any time as described in the authorization. Your revocation will be effective for all your medical information that we maintain, unless we have taken action in reliance on your authorization.
What Rights Do You Have Regarding Your Medical Information?
- The Right to Request Additional Restrictions on Uses and Disclosures of Your Medical Information. You have the right to ask that we put additional restrictions on how we use and disclose your medical information. We do not have to agree to your request.
- The Right to Inspect and Copy Your Medical Information. You have the right to inspect and copy your medical information that we may use to make decisions about you. In limited circumstances, we do not have to agree to your request.
- The Right to Amend or Correct. If you feel that your medical information is incorrect or incomplete, you have the right to ask us to correct or amend the information. We will require that you submit the request in writing and explain your reasons for asking for an amendment. In some cases, we do not have to agree to your request.
- The Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters by a different means or at a different location than what we are currently doing. In limited circumstances, we do not have to agree to your request.
- Paper Copy of this Notice. You have the right to request and receive a paper copy of this notice.
- The Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we and our business associates made for certain purposes for the last six (6) years.
If you want to exercise any of these rights described in this notice, please direct your inquiry to our Privacy Official at email@example.com
How to Complain About Our Privacy Practices. If you think we may have violated your privacy rights, you may file a complaint with our Privacy Official at firstname.lastname@example.org. We will take no retaliatory action against you if you file a complaint about our privacy practices.