Notice of HIPAA Privacy Policy

Effective Date : August 2016, Last Updated February 2023
This notice describes how protected health information about you may be used and disclosed and
how you can get access to this information.
Please review carefully.
If you have any questions about this notice, please contact:
Simplex Health
info@simplexhealth.com
300 Brookside Ave Bldg 18 Ste 180
Ambler, PA 19002
Phone# 484-416-4243

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION
We, Simplex Health understand that protected health information about you and your health is
personal and we are committed to protecting your personal health information.
We are required by law to maintain the privacy of protected health information. “Protected health
information” includes any identifiable information that we obtain from you or others that relates to
your physical or mental health, the health care you have received, or payment for your health care.
As required by law, this notice provides you with information about your rights and our legal
duties and privacy practices with respect to the privacy of protected health information. This
notice also discusses the uses and disclosures we will make of your protected health
information.
We must comply with the provisions of this notice. However, we reserve the right to change this
Notice and make the new Notice apply to health information we already have, as well as any
information we receive in the future. We will make notification of changes by:

  • Posting the revised Notice in our office;
  • Making copies of the revised Notice available upon request; and
  • Posting the revised Notice on our Web site.

Retention & Deletion
We will only retain your Personal Information for as long as necessary to fulfill the purposes for which it was collected and processed, including for the purposes of satisfying any legal, regulatory, accounting or reporting requirements. In some circumstances, we may de-identify, aggregate, or otherwise anonymize your Personal Information consistent with applicable laws and industry standards so that it can no longer be associated with you, in which case it is no longer treated as Personal Information. It is our policy to retain Personal Information for ten (10) years once such Personal Information is no longer necessary to deliver the Services and to delete such Personal Information thereafter. This means that, if you close your account with us, we will delete Personal Information associated with your account after ten (10) years. Regarding other types of information we collect as described in this policy it is our policy to retain such information for ten (10) years and to delete such Personal Information thereafter.

Federal law requires us to:

  • Make sure that protected health information that identifies you is kept private;
  • Notify you about how we protect protected health information about you;
  • Explain how, when, and why we use and disclose protected health information; and
  • Follow the terms of the Notice that is currently in effect.

Permitted Uses and Disclosures of your Protected Health Information
The following categories describe different ways that we may use and disclose protected health
information without your written authorization.

For Treatment: We may use protected health information about you to provide you with, coordinate,
or manage your medical treatment or services. We may disclose protected health information about
you to doctors, nurses, technicians, medical students, or other personnel, including persons outside of
our office who are involved in your medical care.
[Insert clinic name] staff may also share protected health information about you in order to
coordinate your care for such reasons as prescriptions, lab work, and x­rays.
We may use and disclose protected health information to contact you as a reminder that you have an
appointment for treatment or medical care at [insert clinic name]. We may use and disclose protected
health information to tell you about or recommend possible treatment options, treatment
alternatives, or health-­related benefits or services that may be of interest to you.
For Payment for Services: We may use and disclose protected health information about you so that
the treatment and services you receive at Simplex Health may be billed to and payment may be
collected from you, an insurance company, or a third party. For example, we may need to give your
health plan information about nutrition services you received at Simplex Health so your health plan
will pay us or reimburse you for the service. We may also tell your health plan about the nutrition
services you are going to receive to obtain prior approval or to determine whether your plan will
cover the treatment.
For Health Care Operations: We may use and disclose protected health information about you for
Simplex Health care operations, such as our quality assessment and improvement activities, case
management, coordination of care, business planning, customer service, and other activities. These
uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all
of our patients receive quality care.
For example, we may use protected health information to review our treatment and services or to
evaluate the performance of the dietitian who is providing your services. We may also combine
protected health information about many Simplex Health patients to decide what additional services
Simplex Health should offer, what services are not needed, and whether certain treatments are
effective. We may also disclose information to doctors, nurses, technicians, medical students, and
other Simplex Health personnel for review and learning purposes. Subject to applicable state law, the law allows or requires us to use or disclose your health
information without your authorization in some limited situations for purposes beyond treatment,
payment, and operations.

 

As Required by Law: We will disclose protected health information about you when required to do so
by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information
when necessary to prevent a serious threat to your health and safety or the health and safety of the
public or another person.
We may also disclose protected health information about you to a government authority if we
reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only disclose
this type of information to the extent required by law, and we will only disclose it if (a) you agree to
the disclosure, or (b) the disclosure is allowed by law and we believe it is necessary to prevent or
lessen a serious and imminent threat to you or another person.
Judicial and Administrative Proceedings. We may disclose your protected health information in
response to a court or administrative order. We may also disclose your protected health information
in response to a subpoena, discovery request, or other lawful process by someone else involved in the
dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the
request or to obtain an order protecting the information requested.
Business Associates. We may disclose information to business associates who perform services on our
behalf (such as billing companies). However, we require that these associates appropriately safeguard
your information. Our business associates are obligated to protect the privacy of your information and
are not allowed to use or disclose any information other than as specified in our contract.
Public Health. As required by law, we may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease, injury, or disability.
Health Oversight Activities. We may disclose protected health information to a health oversight
agency for activities authorized by law. These activities include audits, investigations, and inspections,
as necessary for licensure and for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Law Enforcement. We may release protected health information as required by law, or in response to
an order or warrant of a court, a subpoena, or an administrative request. We may also disclose
protected health information in response to a request related to identification or location of an
individual, a victim of crime, a decedent, or a crime on the premises.

Organ and Tissue Donation. If you are an organ donor, we may release protected health information
to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue
transplantation, as necessary to facilitate organ or tissue donation and transplantation.
Special Government Functions. If you are a member of the armed forces, we may release protected
health information about you if it relates to military and veterans activities. We may also release your
protected health information for national security and intelligence purposes, protective services for
the President, and medical suitability or determinations made by the Department of State.
Coroners, Medical Examiners, and Funeral Directors. We may release protected health information
to a coroner or medical examiner. This release may be necessary, for example, to identify a deceased
person or determine the cause of death. We may also disclose protected health information to
funeral directors, consistent with applicable laws, to enable them to carry out their duties.
Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a
correctional institution or under the custody of a law enforcement official, we may release protected
health information about you to the correctional institution or law enforcement official as necessary
for your or another person’s health and safety.
Worker’s Compensation. We may disclose protected health information as necessary to comply with
laws relating to worker’s compensation or other similar programs established by law.
Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction
of the FDA, protected health information relative to adverse events with respect to drugs, foods,
supplements, products, and product defects, or post marketing surveillance information to enable
product recalls, repairs, or replacement.
Fundraising. We may also contact you as part of fundraising efforts. You have the right to opt out of
receiving such communications.

 

You can Object to Certain Uses and Disclosures
Unless you object, or request that only a limited amount or type of information be shared, we may
use or disclose protected health information about you in the following circumstances:

  • We may share with a family member, relative, friend or other person identified by you
    protected health information that is directly relevant to that person’s involvement in your
    care or payment for your care. We may also share information to notify these individuals of
    your location, general condition, or death.
  • We may share protected health information with a public or private agency (such as the
    American Red Cross) for disaster relief purposes. Even if you object, we may still share this
    information if necessary under emergency circumstances. If you would like to object to use and disclosure of protected health information in these
    circumstances, please call or write to the contact person listed on page 1 of this Notice.

Your Rights
You have the following rights regarding protected health information that we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy protected health information that
may be used to make decisions about your care or payment for your care. If we maintain your
protected health information electronically, you can request that we provide access in an electronic
form and format that is readily producible, or in a form and format agreed to by us.
To inspect and copy protected health information that may be used to make decisions about you, you
must submit your request in writing to Simplex Health. If you request a copy of the information, we
may charge a fee for the costs of copying, mailing, or supplies associated with your request. We may
not charge you a fee if you need the information for a claim for benefits under the Social Security Act
or any other state or federal needs-­based benefit program. We will respond to your request no later
than 30 days after we receive it. There are certain situations in which we are not required to comply
with your request. In these circumstances, we will respond to you in writing, stating why we will not
grant your request and describe any rights you may have to request a review of our denial.

Right to Amend: If you feel that protected health information we have about you is incorrect or
incomplete, you may ask us to amend or supplement the information.

To request an amendment, your request must be made in writing and submitted to Simplex Health.
In addition, you must provide a reason that supports your request. We will act on your request for an
amendment no later than 60 days after we receive it.

We may deny your request for an amendment if it is not in writing or does not include a reason to
support the request. In these circumstances, we will provide a written denial stating why we will not
grant your request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer
    available to make the amendment;
  • Is not part of the protected health information kept by Simplex Health;
  • Is not part of the information that you would be permitted to inspect and copy; or
  • We believe is accurate and complete.

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.”
This is a list of the disclosures we made of protected health information about you.

To request this list of disclosures, you must submit your request in writing to Simplex Health. You may
ask for disclosures made within the six years before your request. The first list you request within a
12­month period will be free. For additional lists in that 12­month period, we may charge you for the
costs of providing the list. We are required to provide a list of all disclosures except the following:

  • Disclosures made for your treatment;
    Those used for billing and collection of payment for your treatment;
  • Those related to health care operations;
  • Those made to you or requested by you, or those that you authorized;
  • Those that occurred as a byproduct of permitted use and disclosures;
  • Those used for national security or intelligence purposes, or provided to correctional institutions or law enforcement regarding inmates;
  • Those that were a part of a limited data set of information that does not contain information
    identifying you.

Right to Request Restrictions: You have the right to request a restriction or limitation on the
protected health information we use or disclose about you for treatment, payment, or health care
operations, or to persons involved in your care.

We are not required to agree to your request. If we do agree, we will comply with your request unless
the information is needed to provide you emergency treatment, the disclosure is to the Secretary of
the Department of Health and Human Services, or the disclosure is required by law.

To request restrictions, you must make your request in writing to Simplex Health.

Right to Request Confidential Communications: You have the right to request that we communicate
with you about medical matters in a certain way or at a certain location. For example, you can ask
that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Simplex Health.
We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time. To
receive a paper copy, contact info@simplexhealth.com.

Right to Receive Notice of Breach: You have a right to be notified upon a breach of any of your
unsecured protected health information.

Rights for Out­of­Pocket Payments: If you paid out of pocket in full for a specific item or service, you
have a right to ask that your protected health information with respect to that item or service not be
disclosed to a health plan for purposes of payment or health care operations. We are required to
agree to your request unless the disclosure is otherwise required by law.

 

TYPES OF USES AND DISCLOSURES REQUIRING AN AUTHORIZATION
Most uses and disclosures of psychotherapy notes require us to obtain an authorization from you. In
addition, in most instances, we cannot use or disclose your protected health information for
marketing purposes or sell your protected health information without your written authorization.
Finally, any other use or disclosure not described in this Notice will be made only with your authorization. Any time you provide us with a written authorization, you may revoke it any time in writing, to the extent that we have not already taken action in reliance on your previous
authorization.

 

OTHER USES AND DISCLOSURES
We will obtain your written authorization before using or disclosing your protected health
information for purposes other than those described in this Notice (or as otherwise permitted or
required by law). You may revoke this authorization in writing at any time. Upon receipt of the written
revocation, we will stop using or disclosing your information, except to the extent that we have
already taken action in reliance on the authorization.

 

Complaints
If you believe your privacy rights have been violated, you should immediately contact Simplex Health
at .All complaints must be submitted in writing and mailed to the address above.

You may also file a complaint with the Secretary of the Department of Health and Human Services. A
complaint to the Secretary should be filed within 180 days of the occurrence or action that is the
subject of the complaint.

 

Acknowledgement of Privacy Notice
I __________________________________ (print name) acknowledge that I have received a copy of
____________________________ (insert clinic’s name) HIPAA Privacy Practices Notice on this day,
_________________________ (date).
_________________________________________ (patient/client signature)
______________Date