Please see our HIPAA Notice of Privacy Practices and Telehealth Informed Consent forms below.
Please address any questions or complaints to: hello@bircheshealth.com
HIPAA NOTICE OF PRIVACY PRACTICES
This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing. Questions about this notice can be directed to Birches Health.
OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION:
We, Birches Health understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all of the records of your care generated by Birches Health, whether made by Birches Health personnel or your personal doctor or other health care provider. This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The law requires us to:
make sure that protected health information that identifies you is kept private
notify you about how we protect protected health information about you
explain how, when and why we use and disclose protected health information
follow the terms of the Notice that is currently in effect.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by:
posting the revised Notice in our office
making copies of the revised Notice available upon request
posting the revised Notice on our website.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose protected health information without your written authorization.
For Treatment: We may use protected health information about you to provide you with, coordinate or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. Birches Health staff may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside Birches Health’s office who may be involved in your medical care. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Birches Health. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services.
For Payment for Services: We may use and disclose protected health information about you so that the treatment and services you receive at Birches Health may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at Birches Health so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose protected health information about you for Birches Health health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer services and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care. We may also combine protected health information about many Birches Health patients to decide what additional services Birches Health should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Birches Health personnel for review and learning purposes. We may also combine the protected health information we have with protected health information from other health care facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study healthcare and health care delivery without learning who the specific patients are. We may also contact you as part of a fundraising effort. Subject to applicable state law, in some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our facilities.
As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law.
Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Health Risks: We may disclose protected health information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.
Business Associates: We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to appropriately safeguard your information. Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Law Enforcement: We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.
Organ and Tissue Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.
Special Government Functions: If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans’ activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State.
Coroners, Medical Examiners, and Funeral Directors: We may release protected health information 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 disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties.
Correctional Institutions and Other Law Enforcement Custodial Situations: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.
Worker’s Compensation: We may disclose information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Food and Drug Administration: We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:
We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death.
We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances.
If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding protected health information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Birches Health. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.
Right to Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to Birches Health. In addition, you must provide a reason that supports your request. We will act on the/ your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
Is not part of the protected health information kept by Birches Health
Is not part of the information which you would be permitted to inspect and copy, or
We believe 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 protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Birches Health. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following:
For your treatment
For billing and collection of payment for your treatment
For health care operations
Made to or request by you, or that you authorized
Occurring as a byproduct of permitted use and disclosures
For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates
As part of a limited data set of information that does not contain information identifying you
Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing to Birches Health.
Right to Request Confidential Communications: 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 to Birches Health. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time by contacting Birches Health.
OTHER USES AND DISCLOSURES
We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.
YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you believe your privacy rights have been violated, you may file a complaint with Birches Health, or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way.
Patient Authorization & Release
The purpose of this form is to provide you with information about treatment and to obtain your informed consent for a consultation and treatment. If you so consent, the provider (“Provider”) will use telehealth technology to deliver healthcare services to you. This service is not to be used for urgent or emergency consultations. Nor is it a replacement for primary care services.
Nature Of Telehealth: Telehealth is the use of electronic information and communication technologies to enable a healthcare provider and a patient at different locations to share medical information, including, for example, information relating to behavioral health issues. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of some of the following technologies: synchronous video (e.g. videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal communication.
Benefits & Risks: The benefits of telehealth include improved access to health services and care, including the expertise of specialists and consultants who may not otherwise be available to you. There are potential risks to using telehealth technology, including interruptions to the connection, images and other information transmitted may not be clear enough to be useful for the consultation, unauthorized access, and technical difficulties. However, either the Provider or you can discontinue your telehealth visit if the telehealth technologies are not adequate for the situation or if the information obtained via telehealth was not sufficient or if telehealth is inappropriate for any reason. Other potential risks to using telehealth services include breach of privacy of protected health information due to security breaches or failures, as well as adverse drug interactions, allergic reactions, complications, or other errors due to a patient’s failure to provide complete medical information or records.
Alternatives: Alternative methods of care, such as in-person services, may be available to you. You may choose an alternative at any time.
Your Privacy Rights: The Provider uses security protocols to protect the confidentiality of your patient health information. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as permitted or authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in Birches Health’s Privacy Policy and Notice of Privacy practices.
Follow-Up Care; Emergencies: The Provider does not provide primary care services. If a technical failure prevents you from communicating with the Provider, or if you believe telehealth will not provide sufficient safety and quality, you should contact us as indicated below. In the event of an urgent health issue or concern, you must seek care in-person, at a facility or provider equipped to deliver urgent or emergent care. IF THE SITUATION IS AN EMERGENCY, YOU MUST CALL 911.
Phone: (833) 483-3838
Hours of Operation: Monday to Friday, 9am - 5pm (except federal Holidays)
By signing this form, I understand that telehealth involves the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient when the patient is located at a different site than the provider, and I hereby consent to the Provider(s) delivering health care services to me via telehealth.
I understand that telehealth technology will be used in connection with my screening, assessment or management and have been given the opportunity to ask questions regarding the technology. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the Provider, who will be at a distant site. I further understand that the Provider will determine whether telehealth is appropriate for me at this time. I understand that I may benefit from telehealth, but that results cannot be guaranteed. I further understand that my telehealth visit will involve review of my medical data for screening, assessment or management purposes, and that I am responsible for any follow-up with my primary care provider or another specialist regarding any results, concerns, or abnormalities that may be identified based on my screening, assessment or management by the Provider.
The provider will inform me who will be present at the Provider’s location during the telehealth service, and I have the right to exclude anyone from being present, if I so choose. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. In addition, a summary of my visit may also be sent to my primary care provider of record in order to facilitate continuing care. I understand that I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the providers involved in my care. I may be charged a fee for copies of records in accordance with applicable State rules.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care. I may revoke my consent orally or in writing at any time by contacting Birches Health or the Provider.
For purposes of this informed consent, I understand and agree that accepting THE TERMS OF SERVICE SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.
I understand that the Provider has a financial relationship with Birches Health \ and that I am free to obtain a consultation elsewhere.
I understand that I will be responsible for any payments that apply to my telehealth visit. I understand that I may submit claims for these services to any commercial health insurance plan. I also understand that these services will not be reimbursable by any government health insurance plan. I further understand that neither the Provider, Birches Health, nor any facility through which I obtain any imaging, lab work, or testing will submit or facilitate the submission of any claims to my health insurer or other medical benefit plan.
I understand I am responsible for ensuring that I am in an isolated, confidential location with no interruptions for the entirety of my interaction with the Provider and Birches Health and am responsible for engaging in an appropriate manner with the Provider.
I have read and understand the information above and all of my questions have been answered to my satisfaction.
I have read, understand, and agree to the terms of the Birches Health Privacy Policy and Terms of Service.
The Practice may communicate with me, including about my personal medical information, using the methods outlined in the Terms of Service, including without limitation, by email, by leaving me a voicemail message, and by texting me at the mobile number I have provided.
Acknowledgment and Assumption of Risk: I am aware of the dangers and the risks to my person and property involved in participating in treatment including, but not limited, to counseling. I understand that this activity involves certain risks for physical injury. I also understand that there are potential risks of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules, and regulations, and any supervisor’s instructions regarding participation in this activity.
I understand that Birches Health and all associated entities have no responsibility or liability for injury resulting from this activity. I voluntarily elect to participate in this activity with knowledge of the danger involved, and I hereby agree to accept and assume any and all risks of property damage, personal injury, or death.
Waiver of Liability and Indemnification: I understand the contents of this liability waiver form. I have received the opportunity to ask questions and receive satisfactory answers. On behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever: a) waive, release, and discharge Birches Health and its agencies, associated entities officers, directors, and employees from any and all negligence and liability for my death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and b) agree to defend, indemnify, and hold harmless Birches Health and its agencies, associated entities officers, directors, and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participation during this activity or event.
I am voluntarily participating in this treatment. I assume all known and unknown risks of my participation in these treatments and procedures. I agree to indemnify, defend, and hold the healthcare company and all associated parties harmless against all claims and suits of action against liability, compensation, damages, or otherwise brought to me, including attorney fees and related costs. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law. I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
I understand that the above methods of unencrypted communication will be used to communicate with me about Birches Health’s services, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information). I have read the Terms of Service and Privacy Policy.