NOTICE OF PRIVACY PRACTICES  

This Notice describes how protected health information (PHI) about you (or your child) may be used and disclosed at Modyfi. This includes all our staff and contractors at all our sites. This Notice describes how you can access your information and your other privacy rights. We are required by law to l) make sure your medical information is kept private, 2) give you this Notice about our legal duties and privacy practices about your health information and 3) do what we say in the Notice. If you have questions or concerns about privacy of information, you may contact Modyfi at 833-366-3934 or clinic@modyfi.com

Use & Disclosure of Protected Health Information (PHI): 

We may use or disclose information about your treatment for the following reasons: 

• Written Authorization: We have a form you can complete that allows us to share PHI with someone or an organization. 

• Treatment: We use and disclose your PHI to you in order to provide treatment and other services. We may contact you to provide appointment reminders. We may talk to you about alternatives or other benefits and services that may be of interest to you. We may share information between Modyfi mental health providers, clinicians, and support staff in order to coordinate care. We may disclose information for supervision or case consultation within Modyfi. 

• Payment: If ever applicable, we may use and disclose your PHI to obtain payment for services that we provide to you from your insurance plan or payer. 

• Health Care Operations: We may use and disclose your PHI for our health care operations. This includes our internal administration and planning. This also includes various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our providers or therapists. We may also disclose information within Modyfi in order to resolve complaints. 

• Disclosure to Relatives Close Friends and Other Caregivers: We will use or disclose your PHI to a relative, friend, or caregiver only if you are present and we can reasonably infer you do not object to the disclosure. For example, if you bring a friend or relative to a session, we may decide to use or disclose Information for treatment purposes. 

• Public Health Activities: We may disclose PHI for the following public health activities: (1) to report health information to public health authorities for preventing or controlling disease, injury or disability; (2) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (3) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (4) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance. 

• Abuse or Neglect: If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to the appropriate government authority. This includes children, persons who have a mental health diagnosis, and the elderly. We may also disclose PHI if we come in contact with someone who has abused or neglected someone as defined by state laws. 

• Health Oversight Activities: There are organizations that are responsible for overseeing compliance with government rules for delivering healthcare. We may disclose your PHI to such organizations to ensure compliance. 

• Judicial and Administrative Proceedings: We may disclose your PHI in response to a court or administrative order. 

• Law Enforcement Officials: We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. This includes, but is not limited to, identifying or locating missing persons, fugitives, or suspects, or reporting crimes committed on our property. 

• Decedents: We may disclose your PHI to a coroner or medical examiner as authorized by law. We may also disclose PHI as required for any investigation related to a death as allowed by law. 

• Health or Safety: We may use or disclose your PHI to prevent a serious and imminent threat to someone's health or safety. 

• Special Government Functions: We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State when the law requires it. 

• Workers Compensation: We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers' compensation or other similar programs. 

• As required by law: We may use or disclose PHI when required to do so by any other law not listed here. 

Uses and Disclosures of Your Highly Confidential Information 

In addition, federal and state law imposes special privacy protections for "Highly Confidential Information". This includes alcohol and drug abuse treatment program services, HIV/AIDS testing, and genetic testing. To disclose this information (unless allowed or required by law), we will obtain your authorization. 

Coordination with Health Care Providers 

We believe in treating the whole person. So, it is important for us to coordinate care with your other health providers, especially your PCP, and we may ask you to complete a release of information. Both federal and state privacy laws encourage this coordination between health care providers. We only share basic information such as diagnostic information, plans for care, and medications (if they are prescribed). If we need to share other information, it will be only the minimum necessary to coordinate care. You may "restrict" this disclosure if you do not want us to share information with your provider. 

Your Rights Regarding Your Protected Health Information: 

• Complaints: If you want more information about privacy or you have a concern about your privacy at Modyfi, you may contact Modyfi at 833-366-3934 or clinic@modyfi.com. You may also file written complaints with the Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint against us. 

• Right to Request Additional Restrictions: You may request restrictions on our use and disclosure of your PHI. This is for treatment, payment and health care operations. We are not required to agree to the request. To request a restriction, contact our Privacy Officer for the form. We will send you a written response to a completed form. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer. We will say "yes" unless a law requires us to share that information. 

• Right to Request Confidential Communications: You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. 

• Right to Revoke Your Authorization: You may request to revoke an Authorization by contacting Modyfi at info@modyfi.com or 833-366-3934. If we have already used or disclosed information, we cannot take the information back. 

• Right to Inspect and Copy Your Health Information: You may request access to your health information with Modyfi. To access your records, complete a Record request form by contacting us at 833-366-3934 or clinic@modyfi.com. There are limited circumstances where we may deny you access to portions of your record. We are only able to send documents electronically or by fax, no documents will be sent through the mail. If you request a summary of your PHI, we will charge you $150 per hour for completing the summary. 

• Right to Amend Your Records: You may request that we amend PHI at Modyfi. To amend your records, obtain and complete an Amendment Request Form by contacting Modyfi at 833-366-3934 or clinic@modyfi.com. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply. 

• Right to Receive an Accounting of Disclosures: You may request a listing of some types of disclosures of your PHI. This applies to disclosures within the last six years. If you request an accounting more than once during a twelve (12) month period, we will charge you $10.00 for each page of the accounting statement. 

• Right to Be Notified of a Breach: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.