FIELD TRIP MEDICAL, INC. (“Field Trip”)
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.
We typically use or share your health information in the following ways:
Your health information may be used by our workforce members and/or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.
For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by workforce members.
Your health information may be used to seek or obtain payment from your health plan, from other sources of insurance coverage such as an automobile insurer, or from credit card companies that you may use to pay for services.
For example, your health plan may request and receive information regarding dates of service, the services provided, and the medical condition being treated.
Your health information may be used as necessary to support the day-to-day activities and management of Field Trip. This would include but is not limited to running our practice, improving your care and for contacting you when necessary.
For example, information on the services you received may be used to support quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, credentialing activities, budgeting and financial reporting, and other activities to evaluate and promote quality.
We may not use or disclose most psychotherapy notes contained in your protected health information without your authorization.
We are also allowed or required to share your information in other ways, generally in ways that promote the public good such as public health and research. We may have to meet certain conditions in the law before we can share your information for these purposes which include:
We may use or disclose medical information about you in certain situations, such as:
Preventing a serious threat to anyone’s health or safety
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
We will share information about you if local, state, or federal laws require it.
If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about you as a patient of the facility to funeral directors as necessary to carry out their duties.
We can share health information about you in response to a court order or administrative order. We may also disclose medical information about you 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 to tell you about the request or to obtain an order protecting the information requested.
We can use or share your information for health research.
Disclosure of your health information or its use for any purposes other than those listed above may require your written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization.
Without your authorization, we are prohibited from using or disclosing your protected health information for the following purposes:
Sale of your information.
Health plan underwriting.
You have certain rights under the federal privacy standards. These include rights to:
You can ask us for a copy of your health and claims records. Ask us how to do this.
We will provide a copy of a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Contact us for an explanation of our fees.
You can ask us to correct health information about you that you think is incorrect or incomplete. This request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances, in which case we will provide a written explanation within 60 days.
You can ask us to contact you in a specific way (for example, home or office phone) or to send you mail at a different address. We will honor all reasonable requests in this regard, and we must say “yes” if you tell us you would be in danger if we do not.
You can ask us not to use or share certain health information for treatment, payment or health care operations. We are not required to honor your request, and we may say “no” if it would affect your care. Also, 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 honor such requests unless a law requires us to share that information.
You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include in this list all disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make or those made to you).
To request an accounting of disclosures, you must submit your request in writing to the address provided in this notice. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 1, 2020. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
You can ask for a paper copy of this Notice of Privacy Practices at any time, even if you have agreed to receive this notice electronically. Upon request we will provide you with a paper copy promptly.
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 verify that this person has this authority and can act for you before we take any action.
If you have a preference for how we share your information in the circumstances below, contact us. Tell us what you would like us to do, and we will follow your instructions.
Share information with you family, friends, or others involved in payment for your care
Share information in a disaster relief situation
Contact you for fundraising efforts
Send you appointment reminders (such as voice mail messages, text messages, emails, postcards or letters)
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 are required by law to maintain the privacy and security of your protected health information and to provide you with a notice of our related legal duties and privacy practices.
We will let you know promptly if a breach of your information occurs that may have compromised the privacy or security of your protected health information.
We will follow the duties and privacy practices set forth in this notice and provide you with a copy of it.
We will not share your protected heath information other than described herein unless you tell us that we can do so in writing. If you tell us, you may change your mind at any time by letting us know in writing.
We must follow these privacy practices that are described in this Notice while it is in effect.
Some states have enacted privacy laws or other laws respecting the confidentiality of medical information that have requirements different from, and in some cases more stringent than, those described herein. To the extent that an applicable state privacy law imposes requirements that are more restrictive than federal privacy law, the state law will preempt the federal law.
If you would like to submit a comment or complaint about our privacy practices, or request further information regarding our privacy practices, you can do so by contacting us. Our contact information is below.
Address: Field Trip, Attn: Privacy Officer, 1538 20th St. Santa Monica, CA 90404
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 https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf.
You will not be penalized or otherwise retaliated against for filing a complaint.
This notice applies only to Field Trip’s Santa Monica location.
This Notice takes effect , 2020 and will remain in effect until we replace it. We may change the terms of this Notice, and the changes will apply to all information we have about you. The new current will be available upon request, in our office, and on our website at www.fieldtriphealth.com.