GiveBack Enterprises, LLC
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@example.com.
- 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 list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make), except if required by regulation. We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
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.
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: We use health information about you to manage your treatment and services. We may share health information with other entities for their health care operations and other lawful 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
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
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 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