This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
You have the right to:
Get a copy of your health and claims records
Correct your health and claims records
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
Answer coverage questions from your family and friends
Provide disaster relief
Market our services and sell your information
Our Uses and Disclosures
We may use and share your information, including phone number(s) as we:
Help manage your health care treatment, including referrals to other providers
Run our organization
Pay for your health services
Administer your health plan
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of health and claims records
You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on this page.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in payment for your care
Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Marketing purposes
Sale of your information
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information, including phone number(s) in the following ways:
Help manage your health care treatment, including referrals to other providers We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
We can use and disclose your information to run our organization and contact you when necessary.
We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health services
We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan
We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues - we can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
We can share health information about you with organ procurement organizations.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests - we can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
Other Instructions for Notice
Effective Date of this Notice is September 1, 2016
Privacy official is Matthew Muller at msmuller@actdocs.com
We also comply with Texas state privacy laws, including where those laws are more stringent than federal law.
This Notice applies to Acute Care Transitions, LLP, Ft. Worth, TX
CONSENT TO CONSULTATION
Informed Consent to Telemedicine / Telehealth Consultation
Your registration and use of this service is an indication of your consent to receive medical advice and care through a telemedicine or telehealth consultation.
The service consists of access to independent physicians or other health providers contracted through Acute Care Transitions, LLP (“ACT”) via communications technology developed and serviced by CirrusMD Inc. (“CirrusMD”).
ACT and CirrusMD have been contracted on your behalf and for your benefit to provide you with access to health providers in Texas.
By using the service, you acknowledge an intent to seek medical care and the establishment of a consensual patient-physician relationship between yourself and the physician.
You understand the following:
The purpose of the service is to assess and treat my medical condition.
The telemedicine or telehealth consult will be completed primarily through asynchronous text exchange, but may involve synchronous audio and video communication when deemed necessary by my physician or health provider. Unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.
Since telemedicine or telehealth providers are in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or those with medical decision-making authority for me. ACT and CirrusMD cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.
My identity is that represented during the registration process, and I will not allow the use of my account on the CirrusMD platform by other individuals, unless
the individual has my permission to communicate on my behalf, and
that individual is identified separately at the beginning of the telemedicine or telehealth encounter.
An accurate description of the history of my illness, my past medical history, my current medications, and any medical allergies are my responsibility to disclose to the provider.
My provider may direct me to obtain an additional in-person medical evaluation, based on his or her medical judgment, and it is my responsibility to adhere to such instructions provided by my provider.
I can ask questions and seek clarification of services and technology.
I can ask that the telemedicine or telehealth exam and/or audio or videoconference be stopped at any time.
I should contact emergency services by dialing 911 in the event of a medical emergency. A medical emergency is an event that I reasonably believe threatens my or someone else’s life or limb in such a manner that immediate medical care is needed to prevent death or serious impairment of health. A medical emergency includes severe pain, bad injury, a serious illness, or a medical condition that is quickly getting much worse.
I know there are potential risks with the use of communication technology. These include but are not limited to:
Interruption of the communication technology.
A picture or video that is not clear enough to meet the needs of the consultation
Electronic tampering.
If any of these risks occur, my consultation might be stopped. If I am unable to reestablish a connection with my provider, I should contact my primary care physician or emergency services by dialing 911, depending on the severity of my situation.
Additionally, in the event of an adverse reaction to the treatment provided hereunder, I should contact my primary care physician or dial 911, depending on the severity of my situation.
As detailed in this program’s Notice of Privacy Practices, the consultation may be reviewed by medical and non-medical persons for evaluation, informational, research, educational, quality, or technical purposes.
The examination may be reviewed for internal quality review or as might be required by my health coverage plan.
One of the primary purposes of this service is to provide a continuum of care for my safety. In order to accomplish this purpose, it may be necessary for the provider(s) with whom I interact to access my electronic medical records at healthcare systems where I receive care related to my medical condition. By utilizing this service, I agree to allow ACT and the provider(s) interacting with me to access, read, receive, download, and otherwise utilize these medical records for my safety, including but not limited to clinical summaries, test results, and lists of medication and allergies.
I can make a complaint of my provider to the Texas Medical Board by going online at http://www.tmb.state.tx.us/page/place-a-complaint, calling the Complaint Hotline at 800-201-9353, or contacting the Texas Medical Board at the following address:
Texas Medical Board
Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
PO Box 2018, MC-263
Austin, TX 78768-2018
By acknowledgement of this informed consent, I certify I have read the consent, and do hereby understand and state that I agree to the above consents.