Please Read Carefully
Confidentiality of Health Information
Health information that Company receives and/or creates about you, personally, relating to your past, present, or future health, treatment, or payment for healthcare services, may be “protected health information” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”). Your health information may also be protected by state privacy and laws and regulations.
Company understands that health information about you and your health is personal. We support your privacy and make sure that the transmittal and use of your information complies with all laws. In this regard, where applicable, we comply with HIPAA, HITECH, and other relevant state laws and regulations by entering into Business Associate Agreements with the treatment providers for which we provide services to ensure that your protected health information is appropriately safeguarded. While each treatment provider may have its own Notice of Privacy Practices, we also have included M Hospital’s notice below. Please contact each treatment provider for more information regarding its own privacy practices.
Use of Services
Collection of Information
Information You Provide
We collect information you provide, such as when you email us, sign up through our Platform, or submit information through our Platform. We may collect, but are not limited to collecting, the following information: [your name, gender, email address, mailing address, phone number, date of birth, insurance provider information, payment card numbers, bank account number, bank routing number and health information].
Company does not knowingly collect or maintain personally identifiable information from persons under 13 years of age without verifiable parental consent, and no part of the Services are directed at persons under 13. If you are under 13 years of age, then please do not use the Services. If Company learns that personally identifiable information of persons less than 13 years of age has been collected without verifiable parental consent, then Company will take the appropriate steps to delete this information. To make such a request, please contact us at email@example.com.
Information We Collect from Your Use of the Services
We collect information about you when you use our Platform, including, but not limited to the following:
When you register with us using the Platform to create an account and become a registered user, you will need to provide us with certain personally identifiable information to complete the registration, including information that can be used to contact or identify you and payment or other billing information in some cases.
We may automatically collect certain information about the computer or devices (including mobile devices) you use to access the Services. For example, we may collect and analyze information such as (a) IP addresses, geolocation information (as described in the next section below), unique device identifiers and other information about your mobile phone or other mobile device(s), browser types, browser language, operating system, the state or country from which you accessed the Services; and (b) information related to the ways in which you interact with the Services, such as: referring and exit pages and URLs, platform type, the number of clicks, domain names, landing pages, pages and content viewed and the order of those pages, the amount of time spent on particular pages, the date and time you used the Services, the frequency of your use of the Services, error logs, and other similar information. As described further below, we may use third-party analytics providers and technologies, including cookies and similar tools, to assist in collecting this information.
We may collect different types of information about your location, including general information (e.g., IP address, zip code) and more specific information (e.g., GPS-based functionality on mobile devices used to access the Services), and may use that information to customize the Services with location-based information, advertising, and features. For example, if your IP address indicates an origin in Los Angeles, California, the Services may be customized with Los Angeles-specific information and advertisements. In order to do this, your location information may be shared with our agents, vendors or advertisers. If you access the Services through a mobile device and you do not want your device to provide us with location-tracking information, you can disable the GPS or other location-tracking functions on your device, provided your device allows you to do this. See your device manufacturer’s instructions for further details.
Cookies and Other Electronic Technologies
We may use the tools outlined below in order to better understand users. As we adopt additional technologies, we may also gather additional information through other methods.
For more information on cookies, visit http://www.allaboutcookies.org.
“Web Beacons” (a.k.a. clear GIFs or pixel tags) are tiny graphic image files imbedded in a web page or email that may be used to collect anonymous information about your use of our Services, the websites of selected advertisers, and the emails, special promotions or newsletters that we send you. The information collected by Web Beacons allows us to analyze how many people are using the Services, using the selected advertisers’ websites or opening our emails, and for what purpose, and also allows us to enhance our interest-based advertising.
We may use third-party analytics services in connection with the Platform, including, for example, to register mouse clicks, mouse movements, scrolling activity and text that you type into the Platform. These analytics services generally do not collect personal information unless you voluntarily provide it and generally do not track your browsing habits across sites which do not use their services. We use the information collected from these services to help make the Platform easier to use.
Mobile Device Identifiers
Mobile device identifiers are data stored on your mobile device that may track mobile device and data and activities occurring on and through it, as well as the applications installed on it. Mobile device identifiers enable collection of personal information (such as media access control, address and location) and traffic data. Mobile device identifiers help Company learn more about our users’ demographics and internet behaviors.
Information from Third Parties
We may obtain additional information about you from third parties such as marketers, partners, researchers, and others. We may combine information that we collect from you with information about you that we obtain from such third parties and information derived from any other subscription, product, or service we provide.
Aggregate or De-identified Data
Use of Information
We use the information that we collect for the following purposes:
· For the purposes for which you provided the information;
· To contact you when necessary or requested;
· To personalize your experience with the Services by informing you of products, programs, events, services, and promotions of Company, our affiliates, our partners and/or third parties that we believe may be of interest to you (see the “Opt-In Policy” below);
· To fulfill your purchase from us, including, to process your payments, communicate with you regarding your purchase or provide you with related customer service;
· To send mobile notifications (you may opt-out of this service)
· To provide, maintain, administer, improve, or expand the Services, perform business analysis, or for other internal purposes to support, improve or enhance our business, the Services, and other products and services we offer;
· To customize and tailor your experience of the Services;
· To send emails and other communications that display content that we think will interest you and according to your preferences;
· To send you news and information about our Services;
· To track and analyze trends and usage in connection with our Services;
· To better understand who uses the Services and how we can deliver a better user experience;
· To use statistical information that we collect in any way permitted by law, including from third parties in connection with their commercial and marketing efforts;
· To prevent, detect, and investigate security breaches, fraud, and other potentially illegal or prohibited activities;
· To enforce the legal terms that govern your use of the Services;
· To protect our rights or property;
· To administer and troubleshoot the Services; and
· For any other purpose disclosed to you in connection with our Services.
We may use third-party service providers to process and store personal information in the United States and other countries.
Sharing of Information
We may share personal information about you as follows:
· With third parties to provide, maintain, and improve our Services, including service providers who access information about you to perform services on our behalf;
· With our affiliates, partners or other third parties to allow them to contact you regarding products, programs, services, and promotions that we and/or they believe may be of interest to you (See the “Opt-In Policy” below);
· In connection with, or during the negotiation of, any merger, sale of company stock or assets, financing, acquisition, divestiture or dissolution of all or a portion of our business (but only under non-disclosure and confidentiality agreements and protections);
· If we believe that disclosure is reasonably necessary to comply with any applicable law, regulation, legal process or governmental request; to enforce applicable user agreements or policies; to protect the security or integrity of our Services; and to protect us, our users or the public from harm or illegal activities; and
· With your consent.
We may also share aggregated, non-personally identifiable information with third parties.
When you supply us with personally identifiable information in connection with your use of the Services, you may be asked to indicate whether you are interested in receiving information from us about our product and service offerings and if you would like us to share personally identifiable information about you with our affiliates, partners or other third parties for their marketing purposes. If you do choose to opt-in, you will receive such communications and/or we will share your information in accordance with your “opt-in” consent.
You may, of course, choose not to receive additional marketing information from us or choose not to allow our sharing of your personally identifiable information as follows: At any time, you can follow a link provided in our marketing-related email messages (but excluding e-commerce confirmations and other administrative emails) to opt out from receiving such communications; or at any time, you can contact us in accordance with the “Contact Us” section below to opt out from receiving such communications.
If you decide to contact us to change your contact preferences to opt out of receiving communications from us, please specify clearly which of the following choices you are opting out of: (a) Receiving marketing communications from us; (b) Allowing us to share personally identifiable information about you with our affiliates and partners for their marketing purposes; and/or (c) Allowing us to share personally identifiable information about you with other third parties for their marketing purposes.
We will endeavor to implement your requested change as soon as reasonably practicable after receiving your request. Please be aware that your requested change will not be effective until we implement such change. Please note that if you choose not to allow our sharing of your personally identifiable information, we are not responsible for removing your personally identifiable information from the databases of third parties with which we have already shared your personally identifiable information as of the date that we implement your request. If you wish to cease receiving marketing-related emails from these third parties, please contact them directly or utilize any opt-out mechanisms in their privacy policies or marketing-related emails.
Please note that if you do opt-out of receiving marketing-related messages from us, we may still send you important administrative messages. You cannot opt-out from receiving these administrative messages. We reserve the right, from time to time, to contact former customers or users of the Services for administrative purposes or in order to comply with applicable laws, rules or regulations.
Social Media and Third Party Platforms
We take reasonable measures, including administrative, technical, and physical safeguards, to help protect personal information from loss, theft, misuse, unauthorized access, disclosure, alteration, and destruction. Unfortunately, no data transmission over the Internet can be guaranteed to be 100% secure. As a result, while we strive to protect your personal information, Company cannot ensure or warrant the security of any information you transmit to us or from our online products or services, and you do so at your own risk.
Your Privacy Choices
How You Can Access and Update Your Information
You may update or correct information about yourself at any time or by emailing us at firstname.lastname@example.org.
Most web browsers are set to accept cookies by default. If you prefer, you can usually choose to set your browser to remove or reject cookies; however, our Services may not function properly if you do so.
Options for Opting out of Cookies and Mobile Device Identifiers
If you are interested in more information about interest-based advertising and how you can generally control cookies from being put on your computer to deliver tailored advertising, you may visit the Network Advertising Initiative’s Consumer Opt-Out link, the Digital Advertising Alliance’s Consumer Opt-Out link or TRUSTe’s Advertising Choices Page to opt-out of receiving tailored advertising from companies that participate in those programs.
Please note that even after opting out of interest-based advertising, you may still see Company’s advertisements that are not interest-based (i.e., not targeted toward you). Also, opting out does not mean that Company is no longer using its tracking tools—Company still may collect information about your use of the Services even after you have opted out of interest-based advertisements and may still serve advertisements to you via the Services based on information it collects via the Services.
How Company Responds to Browser “Do Not Track” Signals
We are committed to providing you with meaningful choices about the information collected on our Platform for third-party purposes, and that is why we provide above the Network Advertising Initiative’s “Consumer Opt-out” link, Digital Advertising Alliance’s Consumer Opt-Out Link, and TRUSTe’s Advertising Choices page. However, we do not recognize or respond to browser-initiated Do Not Track signals, as the Internet industry is currently still working on Do Not Track standards, implementations and solutions. For more information about DNT signals, visit http://allaboutdnt.com.
Links to Other Websites
Our Services may contain links to other websites and those websites may not follow the same privacy practices as Company. We are not responsible for the privacy practices of third party websites. We encourage you to read the privacy policies of such third parties to learn more about their privacy practices.
Your California Privacy Rights
California law permits users who are California residents to request and obtain from us once a year, free of charge, a list of the third parties to whom we have disclosed their personal information (if any) for their direct marketing purposes in the prior calendar year, as well as the type of personal information disclosed to those parties. If you are a California resident and would like to request this information, please submit your request in an email to email@example.com.
No Rights of Third Parties
How to Contact Us
M Hospital, Inc.
Address: 22617 Hawthorne Boulevard
Torrance, California 90505
Phone: +1 (833) 646-7748
Notice of Privacy Practices
1. M Hospital is dedicated to maintaining the privacy of your protected health information (‘PHI’). PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present or future physical or mental health or condition, (b) the provision of healthcare to you, or (c) your past, present, or future payment for the provision of healthcare. In conducting its business, M Hospital inc. may receive and create records containing your PHI. M Hospital is required by law to maintain the privacy of your PHI and to provide you with notice of its legal duties and privacy practices with respect to your PHI.
2. M Hospital inc. must abide by the terms of this Notice while it is in effect. This Notice is in effect from the date noted above until M Hospital inc. replaces it. M Hospital inc. reserves the right to change the terms of this Notice at any time, as long as the changes are in compliance with applicable law. If M Hospital inc. changes the terms of this Notice, the new terms will apply to all PHI that it maintains, including PHI that was created or received before such changes were made. If M Hospital inc. changes this Notice, it will post the new Notice on its Platform and will make the new Notice available upon request.
Uses and Disclosures of PHI
M Hospital inc. may use and disclose your PHI in the following ways:
Treatment, Payment and Healthcare Operations
M Hospital inc. is permitted to use and disclose your PHI for purposes of (a) treatment, (b) payment and (c) healthcare operations. For example:
M Hospital inc. may disclose your PHI to a physician providing Services through the Platform or otherwise in connection with the provision of treatment to you.
M Hospital inc. may use and disclose your PHI to your health insurer or health plan in connection with the processing and payment of claims and other charges.
M Hospital inc. may use and disclose your PHI in connection with its healthcare operations, such as providing customer services and conducting quality review assessments. M Hospital inc. may engage third parties to provide various services for M Hospital inc. If any such third party must have access to your PHI in order to perform its services, M Hospital inc. will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Notice.
· M Hospital inc. is permitted to use and disclose your PHI upon your written authorization, to the extent such use or disclosure is consistent with your authorization. You may revoke any such authorization at any time.
· As Required by Law. M Hospital inc. may use and disclose your PHI to the extent required by law.
· Special Circumstances. The following categories describe unique circumstances in which M Hospital inc. may use or disclose your PHI:
· Public Health Activities. M Hospital inc. may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. M Hospital inc. may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
· Workers’ Compensation. M Hospital inc. may disclose your PHI as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries.
· Health Oversight Activities. M Hospital inc. may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.
· Judicial and Administrative Proceedings. M Hospital inc. may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.
· Law Enforcement. M Hospital inc. may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person.
· M Hospital inc. may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.
· Organ Procurement. M Hospital inc. may, under certain circumstances, use or disclose PHI for the purposes of organ donation and transplantation.
· M Hospital inc. may, under certain circumstances, use or disclose PHI that is necessary for research purposes.
· Threat to Health or Safety. M Hospital inc. may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
· Specialized Government Functions. M Hospital inc., may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. M Hospital inc. may also disclose PHI to federal officials for intelligence and national security purposes.
Your Rights Regarding Your PHI
You have the following rights regarding the PHI maintained by M Hospital inc:
· Confidential Communication You have the right to receive confidential communications of your PHI. You may request that M Hospital inc. communicate with you through alternate means or at an alternate location, and M Hospital inc. will accommodate your reasonable requests. You must submit your request in writing to M Hospital inc.
· You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that M Hospital inc. restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to M Hospital inc. M Hospital inc. is not required to comply with your request. However, if M Hospital inc. agrees to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency.
· Inspection and Copies You have the right to inspect and copy your PHI. You must submit your request in writing to M Hospital inc. M Hospital inc. may impose a fee for the costs of copying, mailing, labor and supplies associated with your request. M Hospital inc. may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, M Hospital inc. will inform you of the reason for the denial, and you may request a review of the denial.
· You have a right to request that M Hospital inc. amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by M Hospital inc. You must submit your request in writing to M Hospital inc. and provide a reason to support the requested amendment. M Hospital inc. may, under certain circumstances, deny your request by sending you a written notice of denial. If M Hospital inc. denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records.
· Accounting of Disclosures You have a right to receive an accounting of all disclosures mHospital has made of your PHI. However, that right does not include disclosures made for treatment, payment or healthcare operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures. You must submit your request in writing to M Hospital inc. and you must specify the time period involved (which must be for a period of time less than six years from the date of the disclosure). Your first accounting will be free of charge. However, M Hospital inc. may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. M Hospital inc. will inform you of such costs in advance, so that you may withdraw or modify your request to save costs.
· Breach Notification You have the right to be notified in the event that M Hospital inc. (or a M Hospital inc. Business Associate) discovers a breach of unsecured PHI.
· Paper Copy You have the right to obtain a paper copy of this Notice from M Hospital at any time upon request. To obtain a paper copy of this notice, please contact M Hospital by calling +1 (833) 646-7748.
· You may complain to M Hospital inc. and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with M Hospital inc., you must submit a statement in writing to M Hospital: Attn: Security Officer, 22617 Hawthorne Boulevard Torrance, California 90505. M Hospital inc. will not retaliate against you for filing a complaint.
· Further Information If you would like more information about your privacy rights, please contact M Hospital by calling +1 (833) 646-7748 and ask to speak to the Privacy and Security Officer. To the extent you are required to send a written request to M Hospital to exercise any right described in this Notice, you must submit your request to M Hospital at: Attn: Security Officer, 22617 Hawthorne Boulevard Torrance, California 90505.
CONSENT TO TELEHEALTH
Please only use our services after you have read this information and subsequently made an informed decision that we are the right provider for you. If you have any questions, please send us a message through our App or Website or email us at firstname.lastname@example.org.
BACKGROUND ON OUR PLATFORM: M. Hospital is a technology platform that patients to receive and doctors to deliver, both through telemedicine visits, as well as in-person visits at home and in the doctor’s office. After an initial video conference or in-person visit, physicians will recommend and prescribe treatment when medically appropriate. The consultation allows you to ask any questions and the physician to evaluate whether you are a good candidate for our telehealth model of care.
BOTH A TELEMEDICINE SOLUTION AND IN-PERSON MEDICAL SERVICES: Please note that M. Hospital and M. Hospital Professional Corporation provide telemedicine, meaning that we are a digital doctor’s office. In circumstances where the standard of care, convenience, or other issues make an in-person examination and treatment more appropriate, we also provide that option. We are here to fill the gaps in the medical care you receive from other sources.
INDEPENDENT PHYSICIANS: Please note that M. Hospital is the platform, but is separate and independent from the physicians who deliver care through the platform. We do our best to verify credentials and allow high quality doctors to deliver care for our platform, but are not responsible for the acts or omissions of individual physicians.
NOT A PHARMACY: Please note that we are not a pharmacy. While we may offer the ease and convenience of necessary mail order medications from a trusted source, as a patient, you have the right to choose to obtain a prescription so that you can obtain the medications from a local or independent pharmacy of your choice. Please message or call us and we will be glad to accommodate your wishes. Please note that we do not send prescriptions to pharmacies based outside the United States, and that we reserve the right to charge additional fees to cover the cost of outside pharmacy support services.
NOT FOR EMERGENCIES: We do not provide care on an emergency basis. Please do not use us in a medical emergency. In an emergency, dial 911 or go to a hospital emergency department.
NO DUTY OF CARE PRIOR TO ACCEPTANCE AS A PATIENT: Please note that the doctor only takes responsibility for your care only after you have created an account, answered all the required health-related questions, made payment, had a video consultation, and the doctor has subsequently reviewed your data – and determined that you are a good candidate for telemedicine services who we are accepting as a patient. Please understand that the duty of care does not begin at the earlier points of answering your questions, making payment, or starting a video visit.
RIGHT TO DECLINE PATIENT: Please understand that the doctor has a right to refuse to take responsibility for your care if, in the doctor’s professional judgment, you are not a good candidate for our service. Completing a visit in the App or Website and making payment, starting a video visit, or sending a message through the app do not, by themselves, create a duty of care or a doctor-patient relationship.
NO PROFESSIONAL MEDICAL ADVICE PRIOR TO ACCEPTANCE: Please note that the only content in the App or Website that constitutes professional medical advice is the advice that a doctor provides in a video visit or the personalized messages the doctor sends you after taking responsibility for your care. Any other content is for information purposes only. No other content in the App or Website constitutes professional medical advice. Information in the health questions about who we can and cannot treat does not constitute professional medical advice. Do not disregard professional medical advice or delay in seeking it because of something you have read on our App or Website.
AGREEMENT TO ANSWER TRUTHFULLY AND USE OUR PLATFORM HONESTLY: You understand that by, using M. Hospital, you accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide all other data in the most accurate form possible. The doctor relies exclusively upon information that you provide to decide whether or not treatment is safe and appropriate, and, if you provide incorrect information, then you will be at greater risk of adverse events from any treatment that the doctor prescribes and you receive that isn’t necessary, appropriate, or safe. It is important that you don’t create more than one account. Creating more than one account makes it impossible for the doctor to see the full history of care that you’ve received from M. Hospital. This increases the chances that the doctor will not have access to important information and photos in you medical record that could influence the doctor’s clinical decision.
CONSENT TO ACCESS MEDICATION HISTORY: You understand that by using M. Hospital, you are giving explicit consent for the doctor to access medication history, where it’s available, from records provided by pharmacy databases via the services of Surescripts and/or DoseSpot.
BENEFITS AND RISKS OF USING OUR SERVICE: We offer care that is convenient, efficient, and affordable. There are differences between traditional settings of care and M. Hospital’s telehealth platform. In using our App and Website, you accept a greater responsibility to read and understand information throughout the App and Website about the limitations of telemedicine, the risks of seeking care this way, and the risks and benefits of a proposed treatment plan. Specifically, you agree to the following risks:
· NEED TO SEEK OTHER SOURCES OF CARE FOR OTHER MEDICAL NEEDS: You need to seek other sources of care for any other medical needs.
· DELAY: There may be a delay until the next business day before a doctor reviews any request for treatment and reads any messages sent. You must check the App or Website for messages because this is the way that the doctor will communicate important information. Failure to check the App or Website regularly may delay care.
· NO IN-PERSON EXAM: By using our telemedicine platform, you will not have an in-person consultation and physical exam that might identify a medical condition that needs further investigation or immediate treatment.
· CONSENT TO COMMUNICATE VIA UNENCRYPTED EMAIL: Our experience is that the overwhelming majority of M. Hospital patients wish to communicate with us via email, even if unencrypted email does not meet HIPAA standards. In signing this consent, you give us permission to use or disclose your medical information to you via the regular email address you provide to us. You acknowledge that we are communicating in this manner irrespective of HIPAA requirements solely at your direction. You may revoke that permission in writing at any time, in which event we will stop any further use or disclosure of your medical information by email, except to the extent we have already acted in reliance on your permission. You understand that we are unable to take back any disclosure we have already made with your permission and that we are required to retain our records of the communications prior to any revocation of authorization to utilize email in communicating with you.
BENEFITS, ALTERNATIVES AND RISKS OF PARTICULAR TREATMENTS: In the course of providing care for you, we may seek to obtain your informed consent for particular treatment recommendations. For example, in some cases, a physician may recommend a treatment that is “off label,” meaning that the physician is recommending use of a drug or device in a way other than what the drug or device was approved for by the Food and Drug Administration (FDA), making it an experimental, non-conventional, or alternative form of treatment. When a treatment has a heightened risk, your doctor may provide a specific informed consent to alert you to the risks, benefits, and alternatives of the particular treatment.
IMPORTANCE OF READING ALL THE INFORMATION WE PROVIDE: You understand that M. Hospital will provide detailed information in the App and Website to help you make an informed decision about whether to accept a proposed treatment plan. The most important information about a treatment plan is in the link that the doctor will send when the doctor prescribes a treatment. This information includes detailed information to help you decide if the benefits of the treatment plan outweigh the risks, given the alternative options available to you, which includes the option of not taking any treatment. You understand the importance of reading the information the doctor provides about adverse events, including the signs and symptoms of serious side effects and common side effects from taking a medicine, as this will ensure that you seek appropriate medical attention in a timely manner.
RISKS OF ACCEPTING OUR TREATMENT PLAN: You understand that all the medicines that the doctor may prescribe or recommend, including over-the-counter medicines and ‘behind-the-counter’ medicines, can cause serious side effects and adverse events that include severe allergic reaction, permanent disability, and death. You understand that it is your responsibility to make an informed decision whether to accept a treatment plan that the doctor proposes after weighing the risks and benefits of the medicine being prescribed, alternative treatment options and the risks and benefits of such alternatives, and the option of not seeking any treatment. You understand the importance of reading the manufacturer’s leaflet that comes with a medicine, including an over-the-counter or behind-the-counter medicine, before taking a medicine because this leaflet includes important information about risks and warnings.
You understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine that the doctor prescribes and any medical conditions you may have, other prescription medicines or other things (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) you are taking, and lifestyle choices such as smoking tobacco products or drinking alcohol.
If you do not understand anything in this Consent or have any other questions, be sure to ask your doctor. If you go forward with treatment, we will assume that you understood and were able to discuss your questions and concerns with your healthcare provider to your satisfaction.
Notice of Privacy Practices
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.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices (the “Notice”) describes M. Hospital (“we” and “our”) practices and those of our employees, staff, volunteers, and other personnel who are involved in your care, including the independent healthcare practitioners who provide care on our platform. We and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. In order to provide you with quality care and to comply with certain state and federal legal requirements, we create a record of the services you receive from us. This Notice applies to all of the records of your care generated by us. This Notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: (1) make sure that medical information that identifies you is kept private; (2) give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) follow the terms of the Notice that are currently in effect, and (4) notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
A WORD ABOUT FEDERAL AND STATE LAW
Federal and state laws both have rules and regulations regarding the protection of your health information. California has long enforced member privacy protections, primarily through the Confidentiality of Medical Information Act (Cal. Civil Code Section 56 et seq.) When California law and federal law differ, federal law requires that providers comply with the federal or state law that provides members with greater protection.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we may use or disclose protected medical information. For each category of uses and disclosures, we will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. Some information such as psychotherapy notes, certain drug and alcohol information, HIV, or mental health information is entitled to special restrictions.
For Treatment. We may use medical information about you to provide you with medical treatment and to coordinate or manage your medical treatment and any related services. We may disclose information about you to our staff or other providers involved in your treatment. We may also disclose your medical information to family members or other individuals involved in your continuing medical care after you leave us. For example, we may share your protected health information between or among our personnel to assist your health care providers in treating you.
For Payment. We may use and disclose medical information about you so that we can get paid for the treatment and services you receive from us. For example, we may need to give information to your health plan or to the Medi-Cal or Medicare program about treatment you receive from us so that they will pay us or reimburse you for your care. We may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose medical information about you to carry out activities that are necessary for our operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, we may use medical information to review treatment and services provided by us or to evaluate the performance of our staff and contractors in caring for you.
To Individuals or Family Members Involved in Your Health Care. Unless you object, we may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. We may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.
For Appointment Reminders. We reserve the right to contact you, in a manner permitted by law, with appointment reminders or information about treatment alternatives and other health related benefits that may be appropriate for you.
Emergencies. We may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, we will use our professional judgment to decide whether this disclosure is in your best interest.
If you would like to object to this disclosure, check here.
For Fundraising Activities. We may use medical information about you to contact you about our sponsored activities including fundraising events. We will only use contact information such as your name, address, and phone number.
As Required By Law. We will disclose your health information when required to do so by federal, state or local law.
Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
For Public Health Activities. We may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) to report deaths; (3) to report abuse or neglect of children, elders, and dependent adults; (4) to report reactions to medications or problems with products; (5) to notify people of recalls of products they may be using; and (6) to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
For Health Oversight Activities. We may disclose medical information about you to a health oversight agency for activities authorized by law.
For Lawsuits and Disputes. We may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Disclosure to Law Enforcement. If asked to do so by law enforcement and as authorized or required by law, we may release medical information: (1) to identify or locate a suspect, fugitive, material witness, or missing person; (2) about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) about a death suspected to be the result of criminal conduct; (4) about criminal conduct; and (5) in case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Decedents. We may release medical information about you 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 to funeral directors. We may also release information to any individual known to us as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
For Specialized Government Functions. We may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.
Information About Inmates/Individuals in Custody. If you are an inmate or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
Disclosure For Threats to Health and Safety. In certain circumstances, we may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
SPECIAL PROVISIONS RELATED TO MEMBER PRIVACY
Psychotherapy Notes. We will not release any psychotherapy notes without a specific authorization from you that allows us to release the notes.
Marketing. We will not release your medical information for marketing purposes without an authorization from you.
Sale of Medical Information. We will not sell your medical information without an authorization from you.
HIV/AIDS Test Results. We will not disclose the results of an HIV/AIDS test unless you give us specific written authorization. We may disclose HIV/AIDS test results without your specific authorization as required by state or federal reporting laws.
You have the following rights regarding your medical information. In order to exercise these rights, you must contact our HIPAA Privacy Officer. You may be asked to submit a written request. The HIPAA Privacy Officer may be contacted using the following information:
Attn: Privacy Officer
22617 Hawthorne Blvd
Torrance CA 90505
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.
Amendment. If you feel that medical information about you is incorrect or incomplete, you may ask us to amend the information.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures that we may have made of your medical information.
Right to Request Restrictions. You have the right to request a restriction or limitation on medical information that we use or disclose about you for treatment, payment or health care operations, and to request a limit on the medical information that we may disclose to family members or friends involved in your care.
Request Confidential Communications. You have the right to request that we communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.
Receive a Copy. You have the right to obtain a copy of this notice.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any we receive in the future. We will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
If you have any questions or believe that your privacy rights have been violated, you may contact our HIPAA Privacy Officer in person or mail a written summary of your concern to the address listed above.
You may also file a complaint with the Department of Health and Human Services as follows:
Michael Leoz, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, we will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosure we have already made with your permission and that we are required to retain its records of the care that we provided to you.
ACKNOWLEDGMENT OF RECEIPT
You acknowledge that you have received the HIPAA Notice of Privacy Practices of M. Hospital.
THE FOREGOING IS ACKNOWLEDGED AS RECEIVED UPON THE EXECUTION OF THE PATIENT SERVICE GREEMENT.