As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION.

This Notice is effective on November 8, 2016.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY:

UroMed is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. When we use or disclose your identifiable health information, we are required to abide by the terms of this notice (or other notice in effect at the time of the use or disclosure)..

To summarize, this notice provides you with the following important information:

The terms of this notice apply to all records containing your identifiable health information that are created or retained by UroMed. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our company has created or maintained in the past, and for any of your records we may create or maintain in
the future. UroMed will post a copy of our current notice in our corporate offices in a prominent location and on our website at www.uromed.com..

You may request a copy of the most current notice from our office or you can access it at www.uromed.com.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Director of Compliance

800-841-1233 / 770-232-5840

C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS WITHOUT YOUR AUTHORIZATION.

  1. Treatment: Means the provision, coordination or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another. For example, your primary care (PCP) physician assigned by your health insurance carrier, who coordinates all of your general health care, may need to know your history of urinary tract infections which is maintained by your urologist. Therefore, your PCP may review your medical records to assess whether you have potential complication conditions and to appropriately order treatment and medical supplies.
  2. Payment. UroMed may use and disclose your identifiable health information in order to bill and collect payment for the items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your medical supplies. We also may use and disclose your identifiable health information to obtain payment from third parties that may be responsible for such costs. Also, we may use your identifiable health information to bill you directly for items.
  3. Health Care Operations means the support functions of our business related to treatment and payment, such as quality assurance activities, case management, receiving and responding to complaints, compliance programs, audits, and other administrative activities. For example, we may use your medical information to evaluate the performance of our staff in providing service to you and other business planning activities.
  4. Disclosures Required by Law. UroMed will use and disclose your identifiable health information when we are required to do so by federal, state or local law.
  5. Health Oversight Activities. UroMed may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for monitoring government programs, compliance with civil rights laws and the health care system in general.
  6. Lawsuits and Similar Proceedings. UroMed may use and disclose your identifiable health information in response to a court or administrative orders, if you are involved in a lawsuit or similar proceeding. We may also disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
  7. Workers’ Compensation. UroMed may disclose your identifiable health information as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
  8. Disclosure to Relatives, Close Friends and Other Caregivers. UroMed may use or disclose your identifiable health information to a family member, other relative, a close personal friend or any other person identified by you when you are available prior to the disclosure if: (1) we obtain your agreement or provide you with the opportunity to object to the disclosure and you do not object; or (2) we reasonably infer that you do not object to the disclosure.
    If you are 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.
  9. Public Health Activities. UroMed may disclose your identifiable health information: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to a government authority authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
  10. Victims of Abuse, Neglect or Domestic Violence. UroMed may disclose your identifiable health information if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority authorized by law to receive reports of such abuse, neglect, or domestic violence.
  11. Law Enforcement Officials. UroMed may disclose your identifiable health information to the police or other law enforcement officials as required by law or in compliance with a court order.
  12. Decedents. UroMed may disclose your identifiable health information to a coroner or medical examiner as authorized by law.
  13. Organ and Tissue Procurement.UroMed may disclose your identifiable health information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
  14. Clinical Trials and Other Research Activities. UroMed may use and disclose your identifiable health information for research purposes pursuant to a valid authorization from you or when an institutional review board or privacy board has waived the authorization requirement. Under certain circumstances, your identifiable health information may be disclosed without your authorization to researchers preparing to conduct a research project, for research or decedents or as part of a data set that omits your name and other information that can directly identify you.
  15. Health or Safety. UroMed may use or disclose your identifiable health information to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
  16. Specialized Government Functions. UroMed may use and disclose your identifiable health information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

D. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION:                                                                                                                                                         

For any purpose other than the ones described above in Section C, we only use or disclose your Protected Health Information when you give us your written authorization.

  1. Marketing. UroMed must obtain your written authorization prior to using your identifiable health information 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.
    UroMed 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.
  2. Sale of Identifiable Health Information. UroMed will not make any disclosure of identifiable health information that is a sale of identifiable health information without your written authorization.
  3. Psychotherapy Notes. UroMed 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.
  4. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain health information about you (“Highly Confidential Information”), including Alcohol and Drug Abuse Treatment Program records and other health information that is given special privacy protection under state or federal laws other than HIPAA. UroMed generally does not maintain any Highly Confidential Information. However, in order for us to disclose any Highly Confidential Information for a purpose other than those permitted by law, we must obtain your authorization.
  5. Revocation of Your Authorization. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Director of Compliance identified above.

E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION.
You have the following rights regarding the identifiable health information that we maintain about you:

  1. Right to Receive Communications by Alternative Means or at Alternative Locations. You have the right to request that UroMed communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a confidential communication, please specify the requested method of contact, or the location where you wish to be contacted. UroMed will accommodate reasonable requests. You do no need to give a reason for your request.
  2. Requesting Restrictions. You may request restrictions on our use and disclosure of your identifiable health information (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 are not required to agree to a requested restriction 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 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. In order to request a restriction in our use or disclosure of your identifiable health information, you must make your request in writing to the Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our company’s use, disclosure or both; and (c) to whom you want the limits to apply.
  3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024, in order to inspect and/or obtain a copy of your identifiable health information. UroMed may charge a reasonable fee for the costs of copying, mailing, labor and supplies associated with your request. UroMed may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.
  4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to the Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024. You must provide us with a reason that supports your request for amendment. UroMed will deny your request if you fail to submit your request (and the reason supporting the request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for UroMed; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by UroMed, unless the individual or entity that created the information is not available to amend the information.
  5. Accounting of Disclosures. All of our clients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures UroMed has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to the Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but UroMed may charge you for additional lists within the same 12-month period. UroMed will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
  6. Right to a Paper Copy of this Notice. You are entitled to receive a copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024.
  7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with UroMed or with the Secretary of the Department of Health and Human Services. To file a complaint with UroMed, contact the Director of Compliance at UroMed, 3975 Johns Creek Court, Suite 100, Suwanee, GA 30024. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint.
  8. Right to Provide an Authorization for Other Uses and Disclosures. UroMed will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You may revoke your authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Director of Compliance at the address provided above. Please note, we are required to retain records of our services.