Notice of Privacy Practices

Last updated: Feburary 12, 2024

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (AS A PATIENT OF EXAMINED LIFE, LLC) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Examined Life, LLC is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you as well as the treatment and services we provide to you. We are required by law to maintain the confidentiality of these records. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain concerning your PHI, and we must follow the terms of this notice.

The terms of this notice apply to all records containing your PHI that are created or retained by Examined Life, LLC. We reserve the right to revise or amend this Notice of Privacy Practices (Notice), any revision or amendment to this notice will be effective for all your records that Examined Life, LLC has created or maintained in the past, and for any records that we may create or maintain in the future. There is a copy of this notice at the front desk of Examined Life, LLC and it is available on our website at www.Examinedlifellc.com. You may obtain a paper copy of this notice by requesting one from Examined Life, LLC.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Privacy Office

276 US-1

York, ME 03909

info@examinedlifellc.com

C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS

The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. Examined Life, LLC may use your PHI to treat you. For example:

(a) You may have laboratory tests (such as blood or urine tests) performed at Examined Life, LLC or an outside provider, and we may use the results to help us reach a diagnosis.

(b) We might use your PHI to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you.

(c) Many of the people who work for Examined Life, LLC –including, but not limited to, doctors, clinical assistants, laboratory technicians, radiology technicians, and nurses – may use or disclose your PHI to treat you or to assist others in your treatment.

(d) We may disclose your PHI to others who may assist in your care, such as your spouse, children or parents.

(e) We may disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment. Examined Life, LLC may use and disclose your PHI to bill and collect payment for the services and items you may receive from us. For example:

(a) We may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.

(b) We may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members, care givers, personal representatives, etc.

(c) We may use your PHI to bill you directly for services and items.

(d) We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health Care Operations. Examined Life, LLC may use and disclose your PHI to operate and improve our business. For instance:

(a) Examined Life, LLC may use your PHI to evaluate the quality of care you received from us, or to conduct cost management and business planning activities for Examined Life, LLC.

(b) We may disclose your PHI to other health care providers and entities who currently have, or have had, a relationship with you in the past in order to assist in their health care operations.

(c) We may use your PHI to obtain accreditation, credentialing or licensing of our doctors or other health care personnel.

4. Health Information Exchanges. Examined Life, LLC may use/share information with other health care providers or information exchanges, such as:

(a) The MaineHealth Ambulatory Electronic Medical Record Program which allows electronic patient medical records stored in a Clinical Data Repository to be available (i) to MaineHealth physicians and allied health professionals working at MaineHealth facilities (such as Maine Medical Center, Stephens Memorial Hospital, Miles Memorial Hospital and St. Andrews Hospital) and (ii) to other area physician practices which participate in the Electronic Medical Record Program. Under this program, we (i) will disclose your PHI to the Maine Health System through their Clinical Data Repository and (ii) may use PHI pertaining to you that has been submitted to the MaineHealth Clinical Data Repository by other of your health care providers to assist us in your treatment. Should you become a patient of Maine Health, your PHI disclosed by Examined Life, LLC will be available to your provider there so that he/she can utilize it for your treatment. Sharing your information with Maine Health may mean that physicians at Maine hospitals or specialist groups will be able to treat you faster or more thoroughly.

(b) The Maine statewide health information exchange through HealthInfoNet. This exchange is designed to connect health care providers throughout the state.

(c) RX-Hub, an information exchange where prescription drug information is shared with participating pharmacies. If you wish to elect to “opt out” or withdraw your information from any of these exchanges or refuse to grant Examined Life, LLC access to information on one specific or any of the health information exchanges listed above please contact the privacy officer.

5. Appointment Reminders. Examined Life, LLC may use and disclose your PHI to contact you and remind you of an appointment.

6. Treatment Options. Examined Life, LLC may use and disclose your PHI to inform you of potential treatment options or alternatives.

7. Health-Related Benefits and Services. Examined Life, LLC may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

8. Release of Information to Family/Friends. Examined Life, LLC may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you; provided that such disclosures will be limited to your PHI that is relevant to their involvement in your care or the payment for your care. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information. If you are present, your PHI will be disclosed to a friend or family member: if we obtain your consent, if we provide you with an opportunity to object and you do not object, or if we reasonably assume that you do not object. If you are not present or you do not have an opportunity to agree or object because of incapacity or emergency, we may make disclosures that, in our professional judgment, are in your best interest.

9. Disclosures Required By Law. Examined Life, LLC will use and disclose your PHI when we are required to do so by federal, state or local law. We will disclose your health information:

(a) On request of a law enforcement official if you are or are suspected to be a victim of a crime and we are unable to obtain your authorization.

(b) To alert a law enforcement official of your death if we suspect your death may have resulted from criminal conduct.

(c) To a law enforcement official when we believe your health information is evidence of criminal conduct that has occurred on our premises.

(d) To a law enforcement official, in an emergency, to report a crime, the location or victims of a crime, and the identity of the person who committed the crime.

(e) To a medical examiner or coroner to identify a deceased person, determine the cause of death, or other duties authorized by law.

(f) To prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

10. Fundraising. If Examined Life, LLC or an organization owned by Examined Life, LLC engages in fundraising, we may use a limited portion of your PHI for this purpose; however, you do have the right to “opt out” or request that your PHI not be used for fundraising. We will honor any requests received in writing by the Privacy Officer.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your protected health information:

1. Public Health Risks. Examined Life, LLC may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

(a) Maintaining vital records, such as births and deaths

(b) Reporting child abuse or neglect

(c) Preventing or controlling disease, injury or disability

(d) Notifying a person regarding potential exposure to a communicable disease

(e) Notifying a person regarding a potential risk for spreading or contracting a disease or condition

(f) Reporting reactions to drugs or problems with products or devices

(g) Notifying individuals if a product or device they may be using has been recalled

(h) Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

(i) Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance

2. Health Oversight Activities. Examined Life, LLC may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Examined Life, LLC may use and disclose your PHI in response to a court or administrative order. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by a party, but only if we have made an effort to inform you of the request or Treehouse Family Medicine, PLLC receives satisfactory evidence that the party issuing the request has complied with the law and reasonable efforts have been made to secure a qualified protective order concerning the information requested.

4. Law Enforcement. Examined Life, LLC may release PHI if asked to do so by a law enforcement official:

(a) Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

(b) Concerning a death we believe has resulted from criminal conduct

(c) Regarding criminal conduct at our offices

(d) In response to a warrant, summons, court order, subpoena or similar legal process

(e) To identify/locate a suspect, material witness, fugitive or missing person

(f) In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. Examined Life, LLC may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information to funeral directors to perform their jobs.

6. Organ and Tissue Donation. Examined Life, LLC may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research. Examined Life, LLC may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an IRB or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to the individual’s privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the Protected Health Information (PHI) will not be re-used or disclosed to another person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

8. Serious Threats to Health or Safety. Examined Life, LLC may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Examined Life, LLC may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National Security. Examined Life, LLC may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials to protect the President, other officials, foreign heads of state, or to conduct investigations.

11. Inmates. Examined Life, LLC may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers’ Compensation. Examined Life, LLC may release your PHI for workers’ compensation and similar programs.

13. Immunizations. Examined Life, LLC may release immunization records to schools, educational institutions, and licensed youth camps with your consent.

E. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications. You have the right to request that Examined Life, LLC communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request specifying the requested method of contact, or the location where you wish to be contacted. Examined Life, LLC will accommodate reasonable requests.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion:

(a) The information you wish restricted;

(b) Whether you are requesting to limit Examined Life, LLC’s use, disclosure or both; and

(c) To whom you want the limits to apply.

We are required to agree to your request to restrict PHI from disclosure to a health plan provided that you have paid 100% for any of the services you request to be restricted.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including your medical record and billing records. You must submit your request in writing to inspect and/or obtain a copy of your PHI. Examined Life, LLC may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Examined Life, LLC may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial, by another licensed health care professional chosen by us. The person who conducts the review will not be the same person who denied your request. We will comply with the decision made on review.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete. To request an amendment, your request must be made in writing and submitted to the Privacy Officer along with reasons that support your request. Your request will be denied if it is not submitted in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by Examined Life, LLC, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures Treehouse Family Medicine, PLLC has made of your PHI excluding disclosures pursuant to a valid authorization, or those made for treatment, payment or healthcare operations. Use of your PHI as part of the routine patient care in Examined Life, LLC is not required to be documented. In order to obtain an accounting of disclosures, you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The first list you request within a 12-month period is free of charge, but Examined Life, LLC may charge you for additional lists within the same 12-month period. Examined Life, LLC will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. Paper copies of this notice are available at the front desk or can be obtained by contacting the Privacy Officer. This notice is also posted on our website, www.examinedlifellc.com

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Examined Life, LLC or with the Secretary of the Department of Health and Human Services. If you wish to file a complaint with Examined Life, LLC, please contact our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Examined Life, LLC will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

9. Right to Notification of Breach of Your Unsecured Health Information. You have a right to notification of any breach of your unsecured PHI. That means you are entitled to receive notice of any access, use or disclosure of your unsecured PHI that is not permitted under applicable law and which is determined to be subject to the breach reporting rules. Following discovery of a breach of your unsecured PHI, we will notify you of the breach by sending written notice to you by first class mail at your last known address. We will notify you following our investigation of the circumstances surrounding the breach, but in no event later than 60 calendar days after the date we discover the breach. We will notify you by telephone or other expedited means, in addition to written notice, in any situation we believe is urgent because of a possible imminent misuse of your unsecured PHI. When required by applicable law, we will also provide notification of a breach to the media and/or to the Secretary of the U.S. Department of Health & Human Services.

If you have any questions regarding this notice or our health information privacy policies, please contact Examined Life, LLC’s Privacy Officer at info@examinedlifellc.com

THE NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

 

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment.

  • Follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.

 

I acknowledge that I have received Examined Life, LLC’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Examined Life, LLC has the right to change its Notice of Privacy Practices from time to time and that I may contact Examined Life, LLC at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.