Your Information. Your Rights. Our Responsibilities.

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.
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. To receive a copy of your records, you can:
    • Access them online through GiveBackRx portal, and select “My Purchases” and “My Profile” to view information stored.
    • Request a printed version by emailing us at [email protected].
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee for printed materials. In some limited circumstances, we may say “no” to your request, and you can ask that the denial be reviewed.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Your request should be in writing and include the reasons for the request for amendment.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days
Request confidential communications
  • You can ask us to contact you in a specific way (for example, home or office phone or to send email) to a different address.
Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we may say “no.” For example, we may refuse your request for a restriction if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure that the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the Secretary of the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions if feasible or required by law.
In these cases, you have both the right and choice to tell us to
  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a facility directory
If you are not able to tell us your preference, for example if you are unconscious or unavailable, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. We may share certain information after you have died.
In these cases, unless allowed by law, we do not share your information unless you give us written permission:
  • Marketing purposes (except as described below)
  • Sale of your information
  • Most sharing of psychotherapy notes
In the case of fund raising
  • We may contact you and use certain information about you for fundraising efforts, but you can tell us not to do so. We may use a business associate or institutionally related foundation for these contacts.
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it, electronically or otherwise, with other professionals who are treating you.
Example: A doctor treating you for an injury asks about your overall health condition. We may share your information for lawful purposes through electronic health information exchange.

Run our organization and engage in other health care operations

We can use and share your health information to run our business, improve your care, and contact you when necessary. We can also share for other health care operations purposes permitted by law or regulations.

Example: A doctor treating you for an injury asks about your overall health condition. We may share your information for lawful purposes through electronic health information exchange.

Bill for services

To the extent applicable, we can use and share your health information to bill and get payment from health plans, from you, or from other entities, or to help other entities get payment.

Example: We give information about you to your health insurance plan so it will pay for your services.

We may give information to entities that help us collect payments. We may share your information with other entities for their payment purposes.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
We can share health information about you for certain situations such as:
  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research as permitted by laws and rules.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations and tissue banks.

Work with a medical examiner or funeral director and share information after death

  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
  • We may share your information after your death to the extent permitted by federal HIPAA rules.

Address workers compensation, law enforcement, and other government requests

We can use or share health information about you:

  • For workers compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond and participate in lawsuits and legal actions

We can share health information about you in response to a court or administrative order or in response to a subpoena. We can also share information when a protective order is in place.

Other uses and disclosures

Business Associates – There are some health-related services provided through contracts with third parties, called “business associates,” that may need the information to perform certain services on our behalf. Examples include software or technology vendors we may utilize to provide technical support, attorneys providing legal services to us, accountants, consultants, billing and collection companies, and others. When such a service is contracted, we may share your protected health information with such business associates and may allow our business associates to create, receive, maintain, disclose, or transmit your information on our behalf in order for the business associate to provide services to us, or for the proper management and administration of the business associate or to enable the business associate to fulfill its legal responsibilities. Business associates must protect any health information they receive from, or create and maintain on our behalf. In addition, business associates may re-disclose your health information for their own proper management and administration, to fulfill their legal responsibilities, and to business associates that are subcontractors in order for the subcontractors to provide services to the business associate. The subcontractors will be subject to the same restrictions and conditions that apply to the business associate. Whenever such an arrangement involves the use or disclosure of your information to our business associate, we will have a written contract with our business associate that contains terms designed to protect the privacy of your information.

De-identified information – We may use and disclose your health information to create de-identified information or limited data sets, and may use and disclose such information as permitted by law.

Inmates – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official as permitted by applicable laws and rules.

Marketing – We may use and disclose your protected health information to communicate face-to-face with you to encourage you to purchase or use a product or service or to provide a promotional gift of nominal value to you. We may also contact you about treatment alternatives or other health-related benefits and services that may be useful to you.

Other Information

Privacy and Security

  • We are required by law to maintain the privacy and security of your protected health information.
  • While we take privacy and security very seriously, sometimes things go wrong. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
    We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
  • We will comply with state law. We will obtain your written consent for certain disclosures if your consent is required under state law.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Other State and Federal Laws

  • We may ask you for consent to share certain medical information. This consent is required by state law for some disclosures and allows us to be certain that we can share your medical information for all of the reasons explained in this notice. For example, we will ask for your consent to share your information for payment purposes. We may also ask for your consent to share certain sensitive information that may have extra protection under state or federal laws. For example, we may ask for your written authorization to disclose information we receive from certain substance abuse facilities.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Effective date: January 27, 2022

This Notice of Privacy Practices applies to the following organization:

Give Back Enterprises, LLC (“GiveBackRx”)
[email protected]
www.givebackRx.com