Effective Date: January 1, 2025
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.
Tri-State Healing Initiative LLC ("our practice") is required by law to maintain the privacy of your Protected Health Information (PHI), to provide you with notice of our legal duties and privacy practices with respect to PHI, and to notify you following a breach of unsecured PHI. We are required to abide by the terms of this Notice while it is in effect.
We Protect Your Information
Your health information is protected under HIPAA and used only for treatment, payment, and healthcare operations.
You Control Your Records
You have the right to access, amend, and request restrictions on how your health information is used.
Transparent Disclosures
We will tell you how your information is used and shared, and obtain your authorization for most other uses.
Your Rights Are Protected
You have the right to file a complaint if you believe your privacy rights have been violated.
The following describes the ways we may use and disclose your PHI. Not every use or disclosure in a category will be listed, but all of the ways we are permitted to use and disclose information will fall within one of the categories.
We may use your PHI to provide, coordinate, or manage your healthcare and any related services. For example, we may disclose your PHI to a specialist to whom we refer you, to a laboratory that performs tests ordered by your provider, or to a pharmacy that fills your prescription.
We may use and disclose your PHI to obtain payment for services we provide to you. For example, we may disclose your PHI to your health insurance company to obtain prior authorization for a procedure or to submit a claim for reimbursement.
We may use and disclose your PHI for our healthcare operations. These activities are necessary to run our practice and ensure that all of our patients receive quality care. Examples include quality assessment activities, employee review activities, training programs, accreditation, certification, licensing, or credentialing activities.
We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or medical care. We may contact you by phone, text message, or email.
We may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. These include, but are not limited to:
You may revoke an authorization at any time, in writing, except to the extent that we have already taken action in reliance on the use or disclosure indicated in the authorization.
You have the following rights regarding your PHI. To exercise any of these rights, please submit a written request to our Privacy Officer at the address listed below.
You have the right to inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI. We may charge a reasonable, cost-based fee for providing you with a copy of your PHI.
You have the right to request an amendment of your PHI for as long as we maintain this information. We may deny your request under certain circumstances.
You have the right to receive an accounting of disclosures we have made of your PHI during the six years prior to the date on which the accounting is requested, except for disclosures made for treatment, payment, or healthcare operations.
You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. 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.
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. We will accommodate reasonable requests.
You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy.
You have the right to be notified following a breach of your unsecured PHI. We will notify you without unreasonable delay and in no case later than 60 days following the discovery of a breach.
We are required by law to:
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.
If you believe that your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer using the information below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
To file a complaint with the Secretary of HHS, visit www.hhs.gov/ocr/privacy/hipaa/complaints/.
Privacy Officer
Tri-State Healing Initiative LLC
2210 Goldsmith Lane, Suite 126-1064
Louisville, KY 40218
Phone: (201) 691-8180
Email: [email protected]