Privacy Statement/Terms and Conditions

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.

Your Rights

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. Ask us how to do this.

• 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.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• 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 mail to a different address.

• We will say “yes” to all reasonable requests.

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” 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). 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 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 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.

Your Choices

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.

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 hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, 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.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

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 with other professionals who are treating you.

Example: A doctor treating you  for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.

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

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.

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.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

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 to 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.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• 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.

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

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 web site.

Effective Date: October 11, 2013

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

This notice is effective as of April 15, 2003

USES AND DISCLOSURE OF HEALTH INFORMATION

Forward Wellness is committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”.  PHI typically includes your name, address, date of birth, billing arrangements, care, and other information that relates to your health, health care provided to you, or payment for health care provided to you.  PHI DOES NOT include information that is de-identified or cannot be linked to you. 

This notice of Health Information Privacy Practices (the “Notice”) describes Forward Wellness’s duties with respect to the privacy of PHI, Forward Wellness’s use of and disclosure of PHI, client rights and contact information for comments, questions, and complaints. 

FORWARD WELLNESS INC.’S PRIVACY PROCEDURES AND LEGAL OBLIGATIONS

Forward Wellness obtains most of its PHI directly from you, through care applications, assessments and direct questions.  We may collect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiries.  We may also obtain PHI from community health care agencies, other governmental agencies or health care providers as we set up your service arrangements.

Forward Wellness is required by law to provide you with this notice and to abide by the terms of the Notice currently in effect.  Forward Wellness reserves the right to amend this Notice at any time to reflect changes in our privacy practices.  Any such changes will be applicable to and effective for all PHI that we maintain including PHI we created or received prior to the effective date of the revised notice.  Any revised notice will be mailed to you or provided upon request.

Forward Wellness is required by law to maintain the privacy of PHI. Forward Wellness will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below.  In order to comply with these state and federal laws, [data_field.company_name] has adopted policies and procedures that require its employees to obtain, maintain, use and disclose PHI in a manner that protects client privacy.

USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as outlined below, Forward Wellness will not use or disclose your PHI without your written authorization.  The authorization form is available from Forward Wellness (at the address and phone number below).  You have the right to revoke your authorization at any time, except to the extent that Forward Wellness has taken action in reliance on the authorization.

The law permits Forward Wellness to use and disclose your PHI for the following reasons without your authorization:

For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication or otherwise provide health care services to you.

To Obtain Payment: We may use or disclose your PHI to insurance companies , government agencies or health plans to assist us in getting paid for our services .  For example, we may release information such as dates of treatment to an insurance company in order to obtain payment. 

For Our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in [data_field.company_name]'s workforce or to companies who help us perform our health services (referred to as "Business Associates") we require these business associates to appropriately protect the privacy of your information .

As Permitted or Required By The Law: In some cases we are required by law to disclose PHI. Such as disclosers may be required by statute, regulation court order, government agency, we reasonably believe an individual to be a victim of abuse, neglect or domestic violence: for judicial and administrative proceedings and enforcement purposes.

For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes.

For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, auditing and for administration of government benefits.

To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public.

Disclosures of Health Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health related products or services offered at Forward Wellness. You have the right not to accept such information.

Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a by-product of a permitted use or disclosure.  Such incidental used and disclosures are permitted as long as Forward Wellness use reasonable safeguards and use or disclose only the minimum amount of PHI necessary.

To Personal Representatives:  We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law.  We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative.

To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care.  These disclosures may occur when you are not present, as long as you agree and do not express an objection.  These disclosures may also occur if you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest.  We may also disclose limited PHI to public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you.  You have the right to limit or stop these disclosures.

YOUR RIGHTS CONCERNING PRIVACY

Access to Certain Records:  You have the right to inspect and copy your PHI in a designated record set except where State law may prohibit client access.  A designated record set contains medical and billing and case management information.  If we do not have your PHI record set but know who does, we will inform you how to get it.  If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them.  If Forward Wellness produces copies for you, we may charge you up to $1.00 per page up to a maximum fee of $50.00.  Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated by Forward Wellness.

Amendments to Certain Records:  You have the right to request certain amendments to your PHI if, for example, you believe a mistake has been made or a vital piece of information is missing.  Forward Wellness is not required to make the requested amendments and will inform you in writing of our response to your request.

Accounting of Disclosures:  You have the right to receive an accounting of disclosures of your PHI that were made by Forward Wellness for a period of six (6) years prior to the date of your written request.  This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order.

Restrictions:  You have the right to request that we agree to restrictions on certain uses and disclosures of your PHI, but we are not required to agree to your request.  You cannot place limits on uses and disclosures that we are legally required or allowed to make.

Revoke Authorizations:  You have the right to revoke any authorizations you have provided, except to the extent that Forward Wellness has already relied upon the prior authorization.

Delivery by Alternate Means or Alternate Address: You have the right to request that we send your PHI by alternate means or to an alternate address.

Complaints & How to contact us:  If you believe your privacy rights have been violated, you have the right to file a complaint by contacting Forward Wellness at the address and/or phone number indicated below.  You also have the right to file a complaint with the Secretary of the United States Department of Health and Human services in Washington, D.C.  Forward Wellness will not retaliate against you for filing a complaint. 

If you believe your privacy rights have been violated, you may make a complaint by contacting Joseph Chavez HIPAA Privacy Officer at (800) 701-0937 or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

The U.S.Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775

Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.

FORWARD WELLNESS INC.

CLIENTS ARE TO BE GIVEN A COPY ALONG WITH A COPY TO BE FILED IN CLIENT CHART

Terms and Conditions

Forward Wellness Staff and/or Clinician Communications

We will be communicating with you by telephone or other means. By signing this informed consent form you are indicating that you are authorizing the Forward Wellness staff and/or your clinician to contact you and/or send phone text and/or email reminders for ALL appointments scheduled and reminders as necessary. Please be sure to inform your clinician if you do not wish to be contacted at a particular time or place, by phone text or email, or by a particular means.

By signing this informed consent you are authorizing Forward Wellness staff and clinicians to contact patients by phone, email, or text for any and all appointment reminders and information necessary for patient care and scheduling.

By signing this informed consent you give Forward Wellness authorization to use the following two HIPAA compliant means to schedule and coordinate patient care, which includes the following:
1) Google BAA covering: Gmail, Google Calendar, Google Drive (including: Docs, Sheets, Slides, and Forms), Google Hangouts (chat messaging feature only), Google Chat, Google Meet, Google Keep, Google Cloudsearch, Google Sites, Google Groups, Google Tasks, Google Voice (manage users only), Jamboard, Google Vault Services, Google Cloud Identity Management.
2) Acuity Scheduling BAA covering all patient scheduling.

Email Communication and Risks

Sensitive, clinical information is to be discussed over the phone or in-person as deemed appropriate by the clinician. For appropriate e-mail or text communication you will receive an email and a text from Forward Wellness Staff and your Clinician. Also, your clinician will respond to your e-mail or text within 24 hours. Potential risks of using electronic communication may include, but are not limited to; inadvertent sending of an e-mail or text containing confidential information to the wrong recipient, theft or loss of the computer, laptop or mobile device storing confidential information, and interception by an unauthorized third party through an unsecured network. E-mail messages may contain viruses or other defects and it is your responsibility to ensure that it is virus-free. In addition, e-mail or text communication may become part of the clinical record. You may be charged for time the clinician spends reading and responding e-mail or text messages.