Privacy Policy

VirtualHealthConnect

Below are the Notice of Privacy Practice notifications for the following physician groups.

Community Health Systems

ONLINE CARE NETWORK II P.C.

Community Health Systems Notice of Privacy Practices

06/03 (Rev. 02/10, 09/13)

This Notice Describes How Medical Information about You May Be Used and Disclosed &
How You Can Get Access to This Information
PLEASE REVIEW CAREFULLY.
If you have any questions about this notice, please contact the Facility Privacy Officer.

Who Will Follow This Notice: This notice describes the facility’s practices and how the facility shares your information with others for treatment, payment and health care operations purposes.

• Any health care professional authorized to enter information into your facility chart.
• All departments and units of the facility.
• Any member of a volunteer group allowed to help you while you are in the facility.
• All employees, staff, agents and other facility personnel.
• Health care providers and their authorized representatives who are members of the facility’s organized health care arrangement, or “OHCA.” These health care providers and their authorized representatives will be operationally and/or clinically integrated with the facility, or will otherwise be permitted by law to receive your information. For example, to the extent permitted by law and in accordance with our policies, the facility will share your medical information with doctors who are members of the facility’s medical staff, even if the doctor is not employed by the facility.
• All entities, sites and locations within this facility’s system will follow the terms of this notice. They also may share medical information with each other for treatment, payment and health care operations purposes.

Our Pledge Regarding Medical Information: We understand that medical information about you and your healthcare is personal. We are committed to protecting medical information about you. A record is created of the care and services you receive at this facility. This record is needed to provide the necessary care and to comply with legal requirements. This notice applies to all of the records of your care generated by the facility. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information in the doctor’s office or clinic.

This notice will tell about the ways in which the facility may use and disclose medical information about you. Also described are your rights and certain obligations we have regarding the use and disclosure of medical information.

The law requires the facility to:

• Make sure that medical information that identifies you is kept private;
• Inform you of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect. This notice is effective as of September 23, 2013.

HOW THE FACILITY MAY USE and DISCLOSE YOUR MEDICAL INFORMATION:
Except with respect to Highly Confidential Information (described below), we are permitted to use your health information for the following purposes:

Treatment. Your medical information may be used to provide you with medical treatment or services. This medical information may be disclosed to doctors, nurses, technicians, and others involved in your care at the facility, including employees, volunteers, students and interns at the facility. This includes using and disclosing your information to treat your illness or injury, to contact you to provide appointment reminders or to give you information about treatment options or other health related benefits and services that may interest you.

For example: A doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The doctor may need to tell the dietitian about the diabetes so appropriate meals can be arranged. Different departments of the facility may also share medical information about you in order to coordinate your different needs, such as prescriptions, lab work and x-rays. The facility also may disclose medical information about you to people outside the facility who may be involved in your medical care after you leave the facility, such as family members, home health agencies, and others who provide services that are part of your care.

Payment. Your medical information may be used and disclosed so that the treatment and services received at the facility may be billed and payment may be collected from you, your insurance company and/or a third party. Please note, we will comply with your request not to disclose your health information to your insurance company if the information relates solely to a healthcare item or service for which you have paid out of pocket and in full to us. This restriction does not apply to the use or disclosure of your health information for your medical treatment.

For example: To the extent insurance will be responsible for reimbursing the facility for your care, the health plan or insurance company may need information about surgery you received at the facility so they can provide payment for the surgery. Information may also be given to someone who helps pay for your care. Your health plan or insurance company may also need information about a treatment you are going to receive to obtain prior approval or to determine whether they will cover the treatment.

Health Care Operations. Your medical information may be used and disclosed for purposes of furthering day-to-day facility operations. These uses and disclosures are necessary to run the facility and to monitor the quality of care our patients receive.

For example: Subject to any limitations described in this notice, your medical information may be:

1. Reviewed to evaluate the treatment and services performed by our staff in caring for you.
2. Combined with that of other facility patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective.
3. Disclosed to doctors, nurses, technicians, and other agents of the facility for review and learning purposes.
4. Disclosed to healthcare students, interns and residents.
5. Combined with information from other facilities to compare how we are doing and see where we can improve the care and services offered. Information that identifies you in this set of medical information may be removed so others may use it to study health care and health care delivery without knowing who the specific patients are.

Individuals Involved in Your Care. With your permission, your medical information may be released to a family member, guardian or other individuals involved in your care. They may also be told about your condition unless you have requested additional restrictions. In addition, your medical information may be disclosed to an entity assisting in a disaster relief effort so your family can be notified about your condition, status, and location.

Research. Under certain circumstances, your medical information may be used and disclosed for research purposes.

For example: A research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same conditions. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, balancing the research needs with the patients’ need for privacy of their medical information. Your medical information may be disclosed to people preparing to conduct a research project; for example, helping them look for patients with specific medical needs, so long as the medical information they review does not leave the facility. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the facility.

Marketing Activities. We may, without obtaining your authorization and so long as we do not receive payment from a third party for doing so, 1) provide you with marketing materials in a face-to-face encounter, 2) give you a promotional gift of nominal value, or 3) tell you about our own health care products and services. We will ask your permission to use your health information for any other marketing activities.

Appointment Reminders. Your medical information may be used to contact you as a reminder of an appointment you have for treatment or medical care at the facility.

Treatment Alternatives. Your medical information may be used to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. Your medical information may be used to tell you about health-related benefits or services that may be of interest to you.

Participation in Health Information Exchanges. We may participate in one or more health information exchanges (HIEs) and may electronically share your health information for treatment, payment and permitted healthcare operations purposes with other participants in the HIE – including entities that may not be listed under “Who Will Follow This Notice” on the first page of this notice. Depending on State law requirements, you may be asked to “opt-in” in order to share your information with HIEs, or you may be provided the opportunity to “opt-out” of HIE participation. HIEs allow your health care providers to efficiently access and use your pertinent medical information necessary for treatment and other lawful purposes. We will not share your information with an HIE unless both the HIE and its participants are subject to HIPAA’s privacy and security requirements.

As Required by Law. Your medical information will be disclosed when required to do so by federal, state, or local authorities, laws, rules and/or regulations.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, your medical information will be disclosed in response to a court or administration order, subpoena, discovery request, or other lawful process by someone else involved in the dispute when we are legally required to respond.

Law Enforcement. Your medical information will be released if requested by a law enforcement official:

1. In response to a court order, subpoena, warrant, summons or similar process;
2. To identify or locate a suspect, fugitive, material witness, or missing person;
3. About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
4. About a death we believe may be the result of criminal conduct;
5. In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities. Your medical information will be released to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. Your medical information may be disclosed to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

To Alert a Serious Threat to Health or Safety. Your medical information may be used and disclosed when necessary to prevent a serious threat to your health and safety and that of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Health Oversight Activities. Your medical information may be disclosed to a health oversight facility for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

SPECIAL SITUATIONS:

Organ and Tissue Donation. If you are an organ or tissue donor, your medical information may be released to organizations that handle organ procurement or organ, eye and tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, your medical information may be released as required by military command authorities. If you are a member of the foreign military personnel, your medical information may be released to the appropriate foreign military authority.

Workers’ Compensation. If you seek treatment for a work-related illness or injury, we must provide full information in accordance with state-specific laws regarding workers’ compensation claims. Once state-specific requirements are met and an appropriate written request is received, only the records pertaining to the work-related illness or injury may be disclosed.

Public Health Risk. Your medical information may be used and disclosed for public health activities. These activities generally include the following:

1. To prevent or control disease, injury or disability;
2. To report births and deaths;
3. To report child abuse or neglect
4. To report reactions to medications or problems with products;
5. To notify people of recalls of products they may be using;
6. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
7. To notify the appropriate government 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.

Coroners, Medical Examiners, and Funeral Directors. Your medical information may be released 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 patients of the facility to funeral directors as necessary to carry out their duties.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary for the following reasons:

1. For the institution to provide you with health care;
2. To protect the health and safety of you and others;
3. For the safety and security of the correctional institution.

HIGHLY CONFIDENTIAL INFORMATION:
Federal and/or State law require special privacy protections for certain highly confidential information about you, including your health information that is maintained in psychotherapy notes. Similarly, Federal and/or State law may provide greater protections for the following types of information than HIPAA, in which case we will comply with the law that provides your information with the greatest protection and you with the greatest privacy rights: (1) mental health and developmental disabilities; (2) alcohol and drug abuse prevention, treatment and referral; (3) HIV/AIDS testing, diagnosis or treatment; (4) communicable diseases; (5) genetic testing; (6) child abuse and neglect; (7) domestic or elder abuse; and/or (8) sexual assault. In order for your highly confidential information to be disclosed for a purpose other than those permitted by law, your written authorization is required.

YOUR WRITTEN AUTHORIZATION
We will first obtain your written authorization before using or disclosing your protected health information for any purpose not described above, including disclosures that constitute the sale of protected health information or for marketing communications paid for by a third party (excluding refill reminders, which the law permits without your authorization). If you provide the facility permission to use or disclose your medical information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your medical information for the reasons covered in your written authorization. You understand that we are unable to take back any disclosures already made with your permission, and that we are required to retain our records of the care that the facility provided to you.

ADDITIONAL INFORMATION CONCERNING THIS NOTICE:

Changes To This Notice. We reserve the right to change this notice and make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The facility will post a current copy of the notice with the effective date. In addition, each time you register at, or are admitted to, the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints. You will not be penalized for filing a complaint.
If you believe your privacy rights have been violated, you may file a complaint with the facility or with the Secretary of the Department of Health and Human Services. Some States may allow you to file a complaint with State’s Attorney General, Office of Consumer Affairs or other State agency as specified by applicable State law. To file a complaint with the facility, submit your complaint to the facility’s Privacy Officer in writing. The facility’s Privacy Officer can provide you with contact information for the Secretary of the Department of Health and Human Services as well as the State agency or agencies authorized to accept your complaints.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information the facility maintains about you:
** NOTE: All Requests Must Be Submitted in Writing to the Facility**

Right to Request Access to Your Health Information. You have the right to timely inspect and copy medical information that may be used to make decisions about your care. Such access will be granted by the facility in accordance with applicable law.

To inspect and copy medical information or to receive an electronic copy of the medical information that may be used to make decisions about you, you must submit a written request. If you request a paper copy of your information, we may charge a fee for the cost of copying, mailing or other supplies associated with your request.

If the facility uses or maintains an electronic health record with respect to your medical information, you have the right to obtain an electronic copy of the information if you so choose.

1. You may direct the facility to transmit the copy to another entity or person that you designate provided the choice is clear, conspicuous, and specific.
2. The facility may charge a fee equal to its labor cost in providing the electronic copy (e.g., costs may include the cost of a flash drive, if that is how you request a copy of your information be produced). If you request an electronic copy of your information, we will provide the information in the format requested if it is feasible to do so.

We may deny your request to inspect and copy in some limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional, other than the person who denied your request, will be chosen by the facility to review your request and the denial. The facility will comply with the outcome of the review.

1. A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.
2. The protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person.
3. The request for access is made by the individual’s personal representative, and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment to information kept by or for the facility. Except where individual state laws are more stringent, this facility has a minimum of 60 days to act on your request.

To request an amendment, you must submit a written request. You must also provide a reason that supports your request.

Your request for an amendment may be denied if:

1. Your request is not in writing or does not include a reason to support the request;
2. The medical information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
3. The medical information is not part of the medical information kept by or for the facility;
4. The medical information is not part of the information you would be permitted to inspect and copy; or
5. The medical information is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of your medical information for purposes other than treatment, payment and health care operations. Except where individual state laws are more stringent, this facility has a minimum of 60 days to act on your request.

To request this list or accounting of disclosures:

1. You must submit your request in writing.
2. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003.
3. Your request should indicate in what form you want the list (for example, on paper, electronically).

The first list you request within a12-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 cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have a right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member.

To request restrictions, you must make your request in writing. In your request, you must tell us:

1. What information you want to limit;
2. Whether you want to limit our use, disclosure or both;
3. To whom you want the limits to apply, for example, disclosures to your spouse.

You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations. We are required to honor your request if the health care item or service is paid out of pocket and in full. This restriction does not apply to use or disclosure of your health information related to your medical treatment.

Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

For example: You can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Be Notified of Breach. We will notify you if we discover a breach of your unsecured protected health information.

Right to a Paper Copy of This Notice. You have the right to a copy of this notice. You may ask us to give you a copy at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

NOTICE OF PRIVACY PRACTICES – ONLINE CARE NETWORK II P.C.

For more information, contact:
Online Care Network II P.C. (the “Provider”)
Chief Privacy Officer
75 State St., 26th Floor
Boston, MA 02109
(617) 204-3500

Your Information. Your Rights. Our Responsibilities.
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 electronic medical record
• Correct your electronic medical record
• 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:

• Tell family and friends about your condition
• Provide mental health care
• Market our services and sell your information

Our Uses and Disclosures
We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Continue reading for more detailed information . . .

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 an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record 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 information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is 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 email) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

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.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

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. Upon request, 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.
• 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.
You have the right to tell us to:

• Share information with your family, close friends, or others involved in your care (or not to)

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
• Most sharing of psychotherapy notes

In addition, mental health records may be withheld from you if your provider determines that disclosure would be detrimental to you.

Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and to contact you when necessary. Example: We use health information about you to manage your treatment and services.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
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.M

Comply with the law
e 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
We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
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 upon request.
• We never sell identifiable personal information.
• 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, and your updated instructions will apply to any future requests for information that we receive.
• Federal and state laws may place additional limitations on the disclosure of your health information related to drug or alcohol abuse treatment programs, sexually transmitted diseases, genetic information, or mental health treatment programs. When required by law, we will obtain your authorization before releasing this type of information.

For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

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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.

Patient Bill of Rights
Many states have adopted a patient bill of rights applicable to patients of physicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to the Service is provided to you here on behalf of OCN. Please note that it includes patient responsibilities as well.

A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.

A patient has the right to know who is providing medical services and who is responsible for his or her care.

A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.

A patient has the right to know what rules and regulations apply to his or her conduct.

A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.

A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.

A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.

A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.

A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.

A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.

A patient is responsible for reporting unexpected changes in his or her condition to the Provider.

A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.

A patient is responsible for following the treatment plan recommended by the Provider.

A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.

State Specific Notifications (See Below For State Specific Mental Health Notifications)

FOR CALIFORNIA RESIDENTS
You or your legal representative retains the option to withhold or withdraw consent to receive health care services via the Service at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which you or your legal representative would otherwise be entitled.

All existing confidentiality protections apply.

All existing laws regarding patient access to medical information and copies of medical records apply.

Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

All provisions herein, including your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit.

NOTICE
Medical doctors are licensed and regulated by the Medical Board of California
(800) 632-2322
www.mbc.ca.gov

FOR FLORIDA RESIDENTS
Each provider’s hours are variable. To access a provider’s in-office schedule, go to that provider’s login page where the provider’s in-office hours are posted.

FOR GEORGIA RESIDENTS
Patient Right to Know

The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The patient should be able to provide the physician or practice name, the address, and the specific nature of the complaint.

FOR INDIANA RESIDENTS
Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.

I expressly consent to providers forwarding my patient identifiable information to the third party payor responsible for the Service or its designee. I agree that I will hold harmless said payor(s), American Well Corporation and Provider for any loss of information due to a technical failure.

Notice Concerning Complaints

You may either file a complaint online or download the appropriate complaint form found at http://www.indianaconsumer.com/filecomplaint.asp. If downloading, you must complete, sign, print, and mail it, along with copies of all relevant supporting documentation to:

Consumer Protection Division
Office of the Indiana Attorney General
302 W. Washington St., 5th Floor
Indianapolis, IN 46204

You can also request a complaint form by calling 800-382-5516 or 317-232-6330.

FOR KANSAS RESIDENTS
Notice to Patients: Required Signage for K.A.R. 100-22-6
Prepared by the State Board of Healing Arts
April 5, 2007

NOTICE TO PATIENTS

It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas.

Questions and concerns regarding this professional practice may be directed to:
KANSAS STATE BOARD OF HEALING ARTS
235 S. Topeka Boulevard
Topeka, Kansas 66603
PHONE: (785) 296-7413
TOLL FREE: 1(888) 886-7205
FAX: (785) 296-0852
WEBSITE: www.ksbha.org

FOR LOUISIANA RESIDENTS
The relationship between you and the Provider is not intended to replace the relationship between you and other providers. The relationship between you and the Provider is supplemental. Your primary care physician is responsible for your overall health care management.

FOR MARYLAND RESIDENTS
Our procedure to verify the identification of the individual transmitting the communication:

We verify your identification through the assignment and use of a unique username and password combination. When you sign into the Service, your username and password identify you.

Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to you are personal to you and you must not share them with any other individual.

When you choose a provider, you will set up an appointment time. Provider is hereby providing you with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with you and respond to your questions in real time.

FOR OKLAHOMA RESIDENTS
You always retain the option to withhold or withdraw consent from obtaining health care services via the Service. If you decide that you no longer wish to obtain health care services via the Service, it will not affect your right to future care or treatment, nor will you risk the loss or withdrawal of any program benefits to which you would otherwise be entitled.

Patient access to all medical information transmitted during a telemedicine interaction is guaranteed by the provider and copies of this information are available at stated costs, which shall not exceed the direct cost of providing the copies.

All existing confidentiality protections apply.

Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researches or other entities shall not occur without your consent.

FOR SOUTH DAKOTA RESIDENTS
SHOULD ANY PATIENT WISH TO DISCUSS FEES OR CHARGES, YOU ARE ENCOURAGED TO ASK ABOUT THEM.

FOR TEXAS RESIDENTS
An additional in-person medical evaluation may be necessary to meet your needs if the provider is unable to gather all the clinical information via the Service to safely treat you.

Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.

The response time for emails, electronic messages and other communications can be found on your provider’s login page.

NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353

For more information please visit our website at www.tmb.state.tx.us

AVISO SOBRE LAS QUEJAS
Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos en la Junta de Examinadores Médicos del Estado de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353

Para obtener más información, viwebsite nuestro sitio web en www.tmb.state.tx.us

FOR VIRGINIA RESIDENTS
We are happy to maintain your records while you are an active patient or to transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. We consider patients inactive if they either ask to have their records transferred or they have not been seen in any of our offices for six years. Our policy is to destroy inactive medical records in accordance with the Virginia Department of Health Professions regulations.
These regulations (18VAC85-20-26) state that practitioners must maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:

1. Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;
2. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or
3. Records that are required by contractual obligation or federal law to be maintained for a longer period of time.

Practitioners must post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records can only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. For more information from the Virginia Department of Health Professions, go to

http://www.dhp.virginia.gov/Medicine

.

FOR WISCONSIN RESIDENTS
Patients have the right to receive information regarding fees charged for a health care service, diagnostic test, or procedure identified by the patient and provided by the Provider.

State Specific Mental Health Notifications

FOR COLORADO RESIDENTS
You do not have the right to access your mental health records, but you may receive a summary of such records after termination of the treatment program.

FOR DISTRICT OF COLUMBIA RESIDENTS
Your written authorization (which you provide with respect to disclosures required for treatment, payment and health care operations by agreeing to American Well Corporation’s Terms of Use) is required for disclosure of mental health information. Subject to a limitation imposed by the mental health professional primarily responsible for your diagnosis and treatment, which may be imposed only if necessary to protect you or another from a substantial risk of imminent and serious physical injury, you are entitled to receive a copy of your mental health record within 30 days of receipt of the request.

FOR HAWAII RESIDENTS
Mental health, mental illness, drug addiction and alcoholism records that directly or indirectly identify you shall be kept confidential and may only be disclosed under limited circumstances, including with consent from you or your legal guardian. Disclosures may only be made to third party payors if you are informed and afforded the opportunity to pay directly. If you are a self-pay patient then no disclosure will be made to third party payors. If your access to the Service is provided through an employer or payor arrangement, and a third party pays some or all of the cost of your mental health services, then accessing the Service for this purpose constitutes your agreement to our disclosure of so much information as is required to secure such payment.

FOR MICHIGAN RESIDENTS
As long as you have not been found incompetent and do not have a guardian, you have the right to your mental health records. Provider will provide the records to you within 30 days of receipt of your request, or if you request the records during a course of treatment, by the conclusion or other termination of your course of treatment, if earlier.

FOR MINNESOTA RESIDENTS
Upon written request of your spouse, parent, child or sibling, if you are evaluated for or diagnosed with mental illness, provider must ask you whether you wish to authorize a specific individual to receive information regarding treatment. If authorized, provider shall communicate about your treatment with such individual. In addition, a Provider providing mental health treatment may disclose limited information to a family member/other person if: the request is in writing; the person lives with, provides care for, or is directly involved in your treatment and that involvement is verified by and documented in the medical record; before disclosure, you are informed in writing of the request, the person making the request, and the reason for the request; your agreement, objection or inability to consent or object is documented in the patient’s record; and disclosure is necessary for the patient’s treatment.

FOR SOUTH DAKOTA RESIDENTS
You have the right of access to your mental health records upon request.