NOTICE OF PRIVACY PRACTICES
Affect Therapeutics, Inc.
Effective Date: January 24, 2022
Affect Provider Group, P.S.C. and Affect Therapeutics, Inc. (“Affect,” “we” or “our”) is required by law to maintain the privacy of your health information in accordance with federal and state law. We protect your health information in accordance with HIPAA and all other applicable law. In particular, we protect the privacy and security of your substance use disorder patient records in accordance with 42 U.S.C. § 290dd–2 and 42 C.F.R. Part 2, the Confidentiality of Substance Use Disorder Patient Records (“Part 2”). This Notice of Privacy Practices (“Notice”) outlines our legal duties and privacy practices with respect to health information. We are required by law to provide you with a copy of this Notice and will notify you following a breach of your unsecured health information.
We will abide by the terms of the Notice. We reserve the right to make changes to this Notice as permitted by law. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page. If we change this Notice, you can access the revised Notice on our website (www.affecttherapeutics.com/hipaa).
You have the right to file a complaint if you believe your privacy rights have been violated. If you would like to file a complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Affect Provider Group, Attn: Privacy Officer, 1640 Boro Place, 4th Floor, McLean, VA 22102 or by contacting our Privacy Officer by telephone at (323) 522-2218, or by email at firstname.lastname@example.org. You also have the right to complain to the Secretary of the United States Department of Health and Human Services, the United States Attorney for the judicial district in which the violation occurs, and the Substance Abuse and Mental Health Services Administration (“SAMHSA”) office responsible for opioid treatment program oversight. You will not be penalized or otherwise retaliated against for filing a complaint.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION:
We will obtain your written authorization to use and disclose your health information unless we are permitted to use or disclose your information without your authorization under applicable law. The following categories describe the ways that we may use and disclose your health information without your written authorization under Part 2. To the extent applicable state law is even more restrictive than Part 2 on how we use and disclose any of your health information, we comply with more restrictive state law.
Within Our Organization. Affect’s personnel who have a need for your information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment may use and share your information.
Emergency Treatment. In the event of a bona fide medical emergency in which your prior authorization cannot be obtained, we may disclose your identifying information to medical personnel. We will obtain your authorization prior to disclosing your information for non-emergent treatment.
Business Associates/Qualified Service Organizations. We may disclose your information to third party “business associates” and “qualified service organizations” that perform various services on our behalf, such as transcription, billing, and collection services, and who agree to protect the privacy of your health information.
Audits. We may disclose your health information to entities who are legally permitted to perform audits of our facilities. Those entities are required to maintain the privacy of your information.
Legal Proceedings. We may disclose your health information pursuant to court orders that meet the requirements of applicable law.
Reporting Crimes on Our Premises or Against Our Personnel. We may disclose a patient’s commission (or threatened commission) of a crime on our premises or against our personnel to a law enforcement agency or official. We are permitted to disclose information regarding the circumstances of such incident, including the suspect’s name, address, last known whereabouts, and status as a patient in our program.
Reporting Child Abuse or Neglect. We may report incidents of suspected child abuse and neglect to the appropriate state or local authorities.
Deceased Persons. We may disclose information relating to the cause of death of a patient under laws requiring the collection of death or other vital statistics or permitting inquiry into the cause of death.
Research. Under certain circumstances, we may disclose your health information to researchers who are conducting a specific research project. Your identifying information will never be published without your written authorization.
FDA Reporting. We may disclose patient identifying information to medical personnel of the Food and Drug Administration (“FDA”) who assert a reason to believe that the health of any individual may be threatened by an error in the manufacture, labeling, or sale of a product under FDA jurisdiction, and that the information will be used for the exclusive purpose of notifying patients or their physicians of potential dangers.
OTHER USES AND DISCLOSURES:
Use or disclosure of your health information for any purpose other than those listed above requires your written authorization. Some examples include:
- Psychotherapy Notes: We will not use and disclose your psychotherapy notes without your written authorization except as otherwise permitted by law.
- Release of Your Presence in Treatment: We will not disclose your presence in treatment to individuals who may contact Affect unless you have provided your written authorization permitting the release.
- Marketing: We will not use or disclose your health information for marketing purposes without your written authorization except as otherwise permitted by law.
- Sale of Your Health Information: We will not sell your health information without your written authorization except as otherwise permitted by law.
If you change your mind after authorizing a use or disclosure of your health information, you may withdraw your permission by revoking the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization. To revoke an authorization, please notify us by mail at Affect Provider Group, Attn: Privacy Officer, 1640 Boro Place, 4th Floor, McLean, VA 22102 or by contacting our Privacy Officer by telephone at (323) 522-2218, or by email at email@example.com.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
This section describes your rights regarding the health information we maintain about you. All requests or communications to exercise your rights discussed below must be submitted in writing to Affect, Attn: Privacy Officer, 1640 Boro Place, 4th Floor, McLean, VA 22102 or by contacting our Privacy Officer by telephone at (323) 522-2218, or by email at firstname.lastname@example.org.
Right to Inspect and Copy. You have the right to inspect and receive a copy of your health information, excluding your psychotherapy notes. We may charge you a fee as authorized by law to meet your request. You may request access to your health information in a certain electronic form and format, if readily producible, or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit such a copy to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. We may deny your request to inspect and copy in limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Request Confidential Communications. You have the right to request that we communicate your health information to you in a certain manner or at a certain location. For example, you may wish to receive information through a written letter sent to a private address. We will grant reasonable requests. We will not ask you the reason for your request.
Right to Amend. You have a right to request that we amend or correct your health information that you believe is incorrect or incomplete. For example, if your date of birth is incorrect, you may request that the information be corrected. To request a correction or amendment to your health information, you must make your request in writing and provide a reason for your request. You have the right to request an amendment for as long as the information is kept by or for us. Under certain circumstances we may deny your request. If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record.
Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you, including most disclosures we make pursuant to your authorization. Your request must state a time period which may not go back further than six years. You will not be charged for this accounting, unless you request more than one accounting per year, in which case we may charge you a reasonable cost-based fee for providing the additional accounting(s). We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.
Right to Request Restrictions. HIPAA provides that you have the right to request restrictions on how your health information is used or disclosed for treatment, payment, or health care operations activities but that we are not required to agree to your requested restriction, unless that restriction is regarding disclosure of health information to your health insurance company and: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information pertains solely to a health care item or service for which you or another person (other than your health insurance company) paid for in full. Note, however, that Part 2 requires that we obtain your written authorization for most disclosures, except as expressly outlined above.
Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. A copy of this Notice can be obtained at any time from our website at joinaffect.com/hipaa
If you have questions or concerns about your privacy rights, or the information contained in this Notice, please contact the Affect Privacy Officer by mail at Affect Provider Group, Attn: Privacy Officer 1640 Boro Place, 4th Floor, McLean, VA 22102 or by contacting our Privacy Officer by telephone at (323) 522-2218, or by email at email@example.com.