Field Trip Health, 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.
This Notice applies to all Field Trip Health Centres, Field Trip Health USA Inc. (Manager) and contractors working in such locations.
Field Trip is required by law to maintain the privacy of your protected health information and to provide individuals with notice of our legal duties and privacy practices with regard to protected health information.
We are also required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach of your unsecured protected health 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 here 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. This Notice takes effect July 2021 and supersedes all prior Notices of its kind and will remain in effect until we replace it.
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. We will provide you with the most recently revised Notice during regular business hours when you visit the office, or we may fax or email it to you if you have agreed to receive electronic communications of this kind. Any changes to our privacy practices will apply to all information we have about you.
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.
For those participating in the And Beyond Program, your health information is shared with contract therapists who provide such services and are Business Associates (defined below).
For those participating in the Cooperative Ketamine Program, your health information is shared with your therapist.
Your health information may be used to seek or obtain payment from your health plan, from other sources of insurance coverage such as a benefits insurer, or from credit card companies that you may use to pay for services. We may also use your health information to collect payment for services provided to you.
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. Please note that information is shared among the Professional Corporation that operate Field Trip Health Centres and the Manager. 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.
There are some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your health information to our business associates so they can perform the jobs we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to agree in writing to safeguard your information appropriately. Business associates include contract medical practitioners, contract therapists in the And Beyond Program and therapists in the Cooperative Ketamine Program, among others.
We are also allowed or required to share your information in other ways, usually which 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 must disclose your health information to you as described in this Notice. We may also disclose your health information to a family member, friend, or other person to the extent it is necessary to do so to assist with your healthcare needs or with payment for your healthcare, but only if you agree that we may do so. If there are individuals to whom you want to give us permission to share such health information with, please let us know by requesting and filling out the necessary form (available upon request).
We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, text messages, emails, postcards, or letters) unless you direct us not to do so.
We may use or disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or other person. Any disclosure, however, would only be to someone able to help prevent the threat.
We will share information about you if local, state, or federal laws require it.
If you are a member of the armed forces, active or reserve, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. For example, we may release medical information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons, or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
About a death we believe may be the result of criminal conduct;
About criminal conduct at the facility; and
In emergency circumstances to report a crime, or the location of the crime.
We may disclose medical information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury, or disability;
To report child abuse or neglect;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using and to provide your social security number and/or other required information to medical device companies and similar organizations regulated by the U.S. Food and Drug Administration (for example, biologic supply companies and donor banks) so that such organizations may locate you should there be a need to do so;
To notify a person who may have been exposed to a disease, or who may be a risk for contracting or spreading a disease or condition; and
To notify the appropriate government or law enforcement authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
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 use or share health information about you for workers’ compensation claims.
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 may release information to a health oversight agency for oversight activities authorized by law.
We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
We can use or share your information for health research. In some jurisdictions, regulatory approval is required for such use. Generally, absent your consent, any such research will be anonymized.
Any other disclosure of your health information or its use for any purposes other than those listed above requires your specific written authorization in most cases. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required by state law to retain our records of the care that we provided to you.
Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes when financial remuneration is involved or for marketing other than face-to-face communication or provision of promotional gifts of nominal value. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information without an authorization. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.
You have certain rights under the federal privacy standards, including Health Insurance Portability and Accountability Act of 1996, as modified in some cases by State laws. These include rights to:
You can ask to see or get a copy of an electronic or paper copy of your medical record and other health information we have about you, with limited exceptions. Usually, this includes medical and billing records, but does not include psychotherapy notes. All such requests must be in writing. You may obtain a form to request access by using the contact information listed on this Notice.
You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so.
Where you request a copy of your medical records for the purpose of supporting a claim or appeal under any provision of the Social Security Act or any federal or state financial needs-based benefit program, a copy will be provided to you or your personal representative free of charge.
Where a copy of your medical records is requested for any other purposes, including personal use or for delivery to your primary care physician or other medical practitioner or therapist, we may impose reasonable, cost-based fees. The fee will include only the cost of copying (including supplies and labor) and postage, if the individual requests that the copy be mailed.
If you request a summary or explanation of your protected health information, we may also charge a fee for preparation of the summary or explanation. The fee shall not include costs associated with searching for and retrieving the requested information.
If you request a format other than photocopies, we will charge a cost-based fee for providing your health information in that format. For example, costs may include the cost of a flash drive, if that is how you request a copy of your information be produced.
If you prefer, we will prepare a summary and or explanation of your health information, also for a fee. Contact us by using the information listed on this Notice for a full explanation of our fees in this regard.
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 of your request.
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.
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 your own pocket in full, you can ask us not to share that information for the purpose of payment 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 this list, 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 the earlier of April 1, 2020 or the opening of your file. 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.
You can complain if you feel we have violated your rights by contacting us as indicated below. You can also 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 or calling 1-877-696-6755. We will not retaliate against you for filing a complaint.
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 here. To the extent that an applicable state privacy law imposes requirements that are more restrictive than federal privacy law, the state law will pre-empt the federal law.
The following is a summary of circumstances where your health information may be shared under state laws:
To other health care professionals in certain instances;
To protect against imminent injury to you or others;
In the case of a medical emergency, if we are unable to contain your consent or, in the case of Massachusetts, you refuse to accept further treatment voluntarily;
In certain legal proceedings and/or pursuant to a court order or subpoena;
Pursuant to requests from certain government agencies and programs, such as healthcare or benefits, or for audits, program evaluations, licensure and accreditation activities;
Other than in Massachusetts, for public health purposes;
To law enforcement in certain instances; and
As otherwise permitted or required by relevant State laws.
Please note that your information may be disclosed orally, in paper form, or electronically.
Please also note that these exceptions are in addition to the uses and disclosures to which you are consenting under this Notice of Privacy Practices and the attached Consent to Treatment and its Schedules.
We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it under the heading “Complaints” below.
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 sending a letter outlining your concerns to the Field Trip Health Privacy Office at:
Field Trip Health Privacy Office
C/O Bennett Jones LLP
135 East 57th Street, Suite 14
New York City, NY 10022
If you believe that your privacy rights have been violated, you should contact us immediately. You will not be penalized or otherwise retaliated against for filing a complaint.
This notice is effective as of July 1, 2021.