The Devine Concierge Medicine – HIPAA Joint Privacy Notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.
Joint Notice is being provided to you on behalf of Devine Concierge
Medicine and the practitioners with clinical privileges that work at
Devine Concierge Medicine with respect to services provided by Devine
Concierge Medicine (collectively referred to herein as “We” or “Our”).
We understand that your medical information is private and
confidential. Further, we are required by law to maintain the privacy
of “protected health information.” “Protected health information” or
“PHI” includes any individually identifiable information that we obtain
from you or others that relates to your past, present or future physical
or mental health, the health care you have received, or payment for
your health care. We will share protected health information with one
another, as necessary, to carry out treatment, payment or health care
operations relating to the services to be rendered by Devine Concierge
As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from Devine Concierge Medicine.
Permitted Uses and Disclosures
can use or disclose your PHI for purposes of treatment, payment and
health care operations. For each of these categories of uses and
disclosures, we have provided a description and an example below.
However, not every particular use or disclosure in every category will
means the provision, coordination or management of your health care,
including consultations between health care providers relating to your
care and referrals for health care from one health care provider to
another. 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. In addition, the doctor may need to contact a physical
therapist to create the exercise regimen appropriate for your treatment.
- Payment means
the activities we undertake to obtain reimbursement for the health care
provided to you, including billing, collections, claims management,
determinations of eligibility and coverage and other utilization review
activities. For example, we may need to provide PHI to your Third Party
Payor to determine whether the proposed course of treatment will be
covered or if necessary to obtain payment. Federal or state law may
require us to obtain a written release from you prior to disclosing
certain specially protected PHI for payment purposes, and we will ask
you to sign a release when necessary under applicable law.
- Health care operations means the support functions of Devine Concierge Medicine, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. For example, we may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you so that others can use the de-identified information to study health care and health care delivery without learning who you are.
Other Uses and Disclosures of Protected Health Information
- We may contact you to provide appointment reminders for treatment or medical care.
may contact you to tell you about or recommend possible treatment
alternatives or other health-related benefits and services that may be
of interest to you.
may disclose to your family or friends or any other individual
identified by you to the extent directly related to such person’s
involvement in your care or the payment for your care. We may use or
disclose your PHI to notify, or assist in the notification of, a family
member, a personal representative, or another person responsible for
your care, of your location, general condition or death. If you are
able, we will give you an opportunity to object to these disclosures,
and we will not make these disclosures if you object. If you are not
able, we will determine whether a disclosure to your family or friends
is in your best interest, taking into account the circumstances and
based upon our professional judgment.
may include certain limited PHI in the Devine Concierge Medicine
directory. This may include your name, location, your general condition
(e.g., fair, stable, etc.) and your religious affiliation. The
directory information, except for your religious affiliation, may be
released to people who ask for you by name. Your religious affiliation
may be given to a member of the clergy, such as a priest or rabbi, even
if they do not ask for you by name. You may request not to be listed in
permitted by law, we may coordinate our uses and disclosures of PHI
with public or private entities authorized by law or by charter to
assist in disaster relief efforts.
will allow your family and friends to act on your behalf to pick up
filled prescriptions, medical supplies, X-rays, and similar forms of
PHI, when we determine, in our professional judgment, that it is in your
best interest to make such disclosures.
may contact you as part of our fundraising and marketing efforts as
permitted by applicable law. You have the right to opt out of receiving
such fundraising communications.
may use or disclose your PHI for research purposes, subject to the
requirements of applicable law. For example, a research project may
involve comparisons of the health and recovery of all patients who
received a particular medication. All research projects are subject to a
special approval process which balances research needs with a patient’s
need for privacy. When required, we will obtain a written
authorization from you prior to using your health information for
- We will use or disclose PHI about you when required to do so by applicable law
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:
- Organ and Tissue Donation.
If you are an organ donor, we may release PHI to organizations that
handle organ procurement or transplantation as necessary to facilitate
organ or tissue donation and transplantation.
- Military and Veterans.
If you are a member of the Armed Forces, we may release PHI about you
as required by military command authorities. We may also release PHI
about foreign military personnel to the appropriate foreign military
- Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.
- Public Health Activities. We may disclose health information about you for public health activities, including disclosures:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
persons subject to the jurisdiction of the Food and Drug Administration
(FDA) for activities related to the quality, safety, or effectiveness
of FDA-regulated products or services and to report reactions to
medications or problems with products;
- 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;
notify the appropriate government authority if we believe that an adult
patient has been the victim of abuse, neglect or domestic violence. We
will only make this disclosure if the patient agrees or when required
or authorized by law.
- to prevent or control disease, injury or disability;
- Health Oversight Activities.
We may disclose PHI to federal or state agencies that oversee our
activities (e.g., providing health care, seeking payment, and civil
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations.
- Law Enforcement. We may release health information if asked to do so by a law enforcement official.
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime under certain limited circumstances;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct on our premises; or
emergency circumstances, to report a crime, the location of the crime
or the victims, or the identity, description or location of the person
who committed the crime.
- In response to a court order, subpoena, warrant, summons or similar process;
- Coroners, Medical Examiners and Funeral Directors.
We may release release PHI to a coroner or medical examiner. We may
also release PHI about patients to funeral directors as necessary to
carry out their duties.
- National Security and Intelligence Activities.
We may release PHI about you to authorized federal officials for
intelligence, counter-intelligence, other national security activities
authorized by law or to authorized federal officials so they may provide
protection to the President or foreign heads of state.
If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release PHI about you to the
correctional institution or law enforcement official. This release
would be necessary (1) to provide you with health care; (2) to protect
your health and safety or the health and safety of others; or (3) for
the safety and security of the correctional institution.
- Serious Threats.
As permitted by applicable law and standards of ethical conduct, we may
use and disclose PHI if we, in good faith, believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public or is necessary
for law enforcement authorities to identify or apprehend an individual.
Other Uses of your Health Information
uses and disclosures of PHI will be made only with your written
authorization, including uses and/or disclosures: (a) of psychotherapy
notes (where appropriate); (b) for marketing purposes; and (c) that
constitute a sale of PHI under the Privacy Rule. Other uses and
disclosures of PHI not covered by this notice or the laws that apply to
us will be made only with your written authorization. You have the
right to revoke that authorization at any time, provided that the
revocation is in writing, except to the extent that we already have
taken action in reliance on your authorization.
HIV related information, genetic information, alcohol and/or substance abuse records, mental health records and certain special conditions related to minors may enjoy certain special confidentiality protections under applicable State and Federal law. Any disclosures of these types of records will be subject to these special protections.
have the right to request restrictions on our uses and disclosures of
PHI for treatment, payment and health care operations. However, we are
not required to agree to your request. We are, however, required to
comply with your request if it relates to a disclosure to your health
plan regarding health care items or services for which you have paid the
bill in full. To request a restriction, you may make your request in
writing to Devine Concierge Medicine.
You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to Devine Concierge Medicine.
You have the right to inspect or obtain a copy of the PHI contained in our records, except:
psychotherapy notes, (e.g., notes that have been recorded by a mental
health professional documenting counseling sessions and have been
separated from the rest of your medical record);
information compiled in reasonable anticipation of, or for use in, a
civil, criminal, or administrative action or proceeding;
- for PHI involving laboratory tests when your access is restricted by law;
you are a prison inmate, and access would jeopardize your health,
safety, security, custody, or rehabilitation or that of other inmates,
any officer, employee, or other person at the correctional institution
or person responsible for transporting you;
we obtained or created PHI as part of a research study, your access to
the PHI may be restricted for as long as the research is in progress,
provided that you agreed to the temporary denial of access when
consenting to participate in the research;
- for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
PHI obtained from someone other than us under a promise of
confidentiality when the access requested would be reasonably likely to
reveal the source of the information.
order to inspect or obtain a copy your PHI, you may submit your request
in writing to Devine Concierge Medicine If you request a copy, we may
charge you a fee for the costs of copying and mailing your records, as
well as other costs associated with your request.
- We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.
- In order to inspect or obtain a copy your PHI, you may submit your request in writing to Devine Concierge Medicine If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.
have the right to request an amendment to your PHI but we may deny your
request for amendment if we determine that the PHI or record that is
the subject of the request:
not created by us, unless you provide a reasonable basis to believe
that the originator of PHI is no longer available to act on the
- is not part of your medical or billing records or other records used to make decisions about you;
- is not available for inspection as set forth above; or
- is accurate and complete.
any event, any agreed upon amendment will be included as an addition
to, and not a replacement of, already existing records. In order to
request an amendment to your health information, you must submit your
request in writing to Devine Concierge Medicine, along with a
description of the reason for your request.
- In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your health information, you must submit your request in writing to Devine Concierge Medicine, along with a description of the reason for your request.
have the right to receive an accounting of disclosures of PHI made by
us to individuals or entities other than to you for the six years prior
to your request, except for disclosures :
- to carry out treatment, payment and health care operations as provided above;
- incidental to a use or disclosure otherwise permitted or required by applicable law;
- pursuant to your written authorization;
- for the Hospital’s directory or to persons involved in your care or for other notification purposes as provided by law;
- for national security or intelligence purposes as provided by law;
- to correctional institutions or law enforcement officials as provided by law;
- as part of a limited data set as provided by law
request an accounting of disclosures of your PHI, you must submit your
request in writing to the Devine Concierge Medicine. Your request must
state a specific time period for the accounting (e.g., the past three
months). The first accounting you request within a twelve (12)-month
period will be free. For additional accountings, we may charge you for
the costs of providing the list. We will notify you of the costs
involved, and you may choose to withdraw or modify your request at that
time before any costs are incurred.
- To request an accounting of disclosures of your PHI, you must submit your request in writing to the Devine Concierge Medicine. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12)-month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.
If you believe that your privacy rights have been violated, you should immediately contact the Devine Concierge Medicine at (610) 510-6876. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services.
If you have any questions or would like further information about this notice, please contact Devine Concierge Medicine at (610) 510-6876.
This notice is effective as of April 20, 2022.