FORWARD NOTICE OF PRIVACY PRACTICES
Last Updated: 10/19/2023
IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.
THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Who We Are
This Notice of Privacy Practices (this “Notice”) describes the privacy practices of each of Clara Medical Group, P.C., Innovative Medical Group FL, PLLC, Innovative Medical Group NY, PLLC, and Innovative Medical Group NJ, LLC (collectively, “Forward,” “we” or “us”), including:
- All healthcare professionals allowed to enter or access information in your medical record; and
- All employees and contractors or others with access to your medical or billing records or health information about you (“Protected Health Information” or “PHI”).
We Are Required by Law to
- Maintain the confidentiality of your PHI in accordance with applicable law;
- Provide you with this Notice of our legal duties and privacy practices with respect to your PHI;
- Comply with the terms of this Notice, as amended or updated from time to time; and
- Notify you in the event of a breach of your unsecured PHI.
We reserve the right to change the terms of this Notice at any time. We may apply those changes to your PHI that is already in our possession. If we make a material change to this Notice, we will promptly post a new Notice in a clear and prominent area on the GoForward website located at [https://goforward.com] and/or the GoForward mobile application. You can also request a copy of the new Notice from [firstname.lastname@example.org].
How May We Use and Disclose PHI?
Uses and Disclosures We May Make Without Your Authorization:
- Treatment. We may use and disclose your PHI 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 PHI to each other to provide treatment to you. We may also disclose your PHI to another health care provider (i.e., who is not part of Forward) so they can provide you with proper care.
- Payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For instance, we may disclose your PHI to your health plan to permit it to make a determination of eligibility or coverage for insurance benefits with respect to services to which we may refer you, to review the services to which we referred you for medical necessity, and to perform utilization review activities. We also disclose PHI 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 PHI to a collection agency. We may also disclose your PHI to other health care providers, health plans or health care clearinghouses for their payment activities, unless disclosure is prohibited by law. For example, we may provide your PHI to an ambulance/transportation company that provided services to you.
- Health Care Operations. We may use and disclose your PHI 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 PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also use your PHI to evaluate and improve products and services provided by our business associates, including GoForward, Inc. In addition, we may use and disclose your PHI 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 PHI to our business associates that assist us in our delivery of healthcare and related services, including GoForward, Inc. (“GoForward”), 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 software platforms that store and/or transmit data on our behalf. Before we disclose your PHI 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 PHI in accordance with law.
- Uses and Disclosures Required by Law. We may use or disclose your PHI as required by law, but we must limit such use or disclosure to relevant information and otherwise comply with applicable legal requirements.
- Public Health Activities. We may use or disclose your PHI 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 disclose your PHI to authorized governmental authorities if we reasonably believe that you are a victim of abuse, neglect or domestic violence.
- Health Oversight Activities. We may disclose your PHI to an authorized agency for certain health oversight activities, including, for example, inspections and licensure or disciplinary actions.
- Judicial and Administrative Proceedings. We may use or disclose your PHI under some circumstances in response to a subpoena or order by a court or administrative tribunal.
- Law Enforcement Purposes. We may disclose your PHI to law enforcement officials under certain circumstances, including, for example, for identification of suspects or where a crime has been committed on our premises.
- Workers' Compensation. We may use or disclose your PHI in order to comply with laws related to workers' compensation and similar programs.
- Decedents. We may disclose PHI to coroners, medical examiners, and funeral directors.
- Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
- Serious Safety Threats. We may use or disclose your PHI 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 PHI under some circumstances for specialized government functions, including those related to the armed forces, national security, and intelligence.
- Personal Representatives. We may disclose your PHI to your personal representatives that are appointed by you or authorized by applicable law.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI 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.
- De-identified information. We may use your PHI to generate de-identified health information, which does not directly identify and could not reasonably be used to identify any specific individual. There are specific rules under the law about what type of information needs to be removed before information is considered de-identified. Once the information has been de-identified as required by law, it is no longer considered PHI and not covered by this Notice. We use this de-identified health information to understand, develop, improve, and market our services, and it may be used or shared with third parties for any lawful purpose without further notice or compensation to you.
- Research. We may disclose health information about you for research purposes, subject to the confidentiality provisions of state and federal law. In most cases, we will ask for your written authorization before using your PHI or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your PHI without your written authorization if an Institutional Review Board or similar body pursuant to applicable law or regulation, applying specific criteria, determines the particular research protocol poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly without your authorization. We may release your PHI without your written authorization to people who are preparing a future research project as long as any information identifying you does not leave Forward or, so long as GoForward continues to be a business associate of Forward, GoForward. Enrollment in a research study is completely voluntary, will not affect your treatment or welfare, and your PHI will continue to be protected.
Uses and Disclosures to which You Have an Opportunity to Agree or Object
- Individuals Involved in Your Care. We may disclose your PHI to a family member, friend or other person whom you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. 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.
Your Authorization Is Needed for Other Uses and Disclosures
Absent your written authorization, Forward will not use or disclose your PHI for purposes beyond what is described in this Notice or as permitted by applicable law or regulation. If you do give Forward written authorization to use or disclose your PHI for purposes beyond what is described in this Notice, then, in most cases, you may revoke such authorization in writing at any time; however any revocation will not apply to the extent that we have already taken action in reliance upon your authorization prior to revocation. Without limiting the foregoing:
- Marketing. We must obtain your written authorization prior to using your PHI 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, case management, care coordination, products, or services unless you have given us your authorization to do so, or the communication is permitted by law.
We may provide refill reminders or communicate with you about a drug or biologic that is currently prescribed to you so long as any payment we receive for making the communication is reasonably related to our cost of making the communication. In addition, we may market to you in a face-to-face encounter and give you promotional gifts of nominal value without obtaining your written authorization.
- Sale of PHI. We will not make any disclosure of PHI that is a sale of PHI without your written authorization.
- Psychotherapy Notes. 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.
What Rights Do You Have Regarding Your PHI?
- The Right to Request Additional Restrictions on Uses and Disclosures of Your PHI. You have the right to ask that we put additional restrictions on how we use and disclose your PHI (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 do not have to agree to your request 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 or regulation 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.
- The Right to Inspect and Copy Your PHI. You have the right to inspect and copy your PHI that we store in your medical record or billing record or that we otherwise use to make decisions about you. If you request copies, we may charge you a reasonable copy fee. In limited circumstances, we may deny you access to a portion of your records.
- The Right to Amend or Correct. If you feel that your PHI 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 if we believe that the information that would be amended is accurate and complete or other special circumstances apply.
- The Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters by a different means of communication or at a different location than what we are currently doing. In some 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 request an accounting more than once during a twelve (12) month period, we may charge you a reasonable fee for the accounting statement.
For More Information or to File a Complaint
If you have questions or want more information about your privacy rights, are concerned that we may have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may file a complaint with us at [email@example.com].
You may also file a written complaint with the U.S. Department of Health and Human Services Office for Civil Rights (OCR). Upon request, we will provide you with the correct address for OCR.
We will take no retaliatory action against you if you file a complaint about our privacy practices with us or OCR.
To ask questions about this Notice, exercise any of your rights described in this Notice, or make a complaint, please contact our Privacy Officer by either:
- Calling us at the following toll-free phone number: 1-833-334-6393, or
- Emailing us at [firstname.lastname@example.org].