Privacy Policy

CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

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.

USES AND DISCLOSURE OF HEALTH INFORMATION

Trost IN LLC (the “Company” or “Trost Health”) is committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”. PHI typically includes your name, address, date of birth, billing arrangements, care, and other information that relates to your health, health care provided to you, or payment for health care provided to you. PHI DOES NOT include information that is de-identified or cannot be linked to you.

This notice of Health Information Privacy Practices (the “Notice”) describes The Company’s duties with respect to the privacy of PHI, The Company’s use of and disclosure of PHI, client rights and contact information for comments, questions, and complaints.

PRIVACY PROCEDURES AND LEGAL OBLIGATIONS

The Company obtains most of its PHI directly from you, through care applications, assessments and direct questions. We may collect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiries. We may also obtain PHI from community health care agencies, other governmental agencies or health care providers as we set up your service arrangements. The Company is required by law to provide you with this notice and to abide by the terms of the Notice currently in effect. The Company reserves the right to amend this Notice at any time to reflect changes in our privacy practices. Any such changes will be applicable to and effective for all PHI that we maintain including PHI we created or received prior to the effective date of the revised notice. Any revised notice will be mailed to you or provided upon request. The Company is required by law to maintain the privacy of PHI. The Company will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below. In order to comply with these state and federal laws, The Company has adopted policies and procedures that require its employees to obtain, maintain, use and disclose PHI in a manner that protects client privacy.

USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as outlined below, The Company will not use or disclose your PHI without your written authorization. The authorization form is available from The Company (at the address and phone number below). You have the right to revoke your authorization at any time, except to the extent that The Company has taken action in reliance on the authorization. The law permits The Company to use and disclose your PHI for the following reasons without your authorization:

For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses, and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication, or otherwise provide health care services to you.

To Obtain Payment: We may use or disclose your PHI to insurance companies, government agencies or health plans to assist us in getting paid for our services. For example, we may release information such as dates of treatment to an insurance company in order to obtain payment.

For Our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in The Company’s workforce or to companies who help us perform our health services (referred to as “Business Associates”) we require these business associates to appropriately protect the privacy of your information.

As Permitted or Required by the Law: In some cases, we are required by law to disclose PHI. Such as disclosers may be required by statute, regulation court order, government agency, we reasonably believe an individual to be a victim of abuse, neglect, or domestic violence: for judicial and administrative proceedings and enforcement purposes.

For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes.

For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, auditing and for administration of government benefits. The Florida Department of Children and Families is an example of an agency that oversees The Company’s operations.

To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public.

Disclosures of Health-Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health-related products or services offered at The Company. You have the right not to accept such information.

Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a byproduct of a permitted use or disclosure. Such incidental used and disclosures are permitted as long as The Company use reasonable safeguards and use or disclose only the minimum amount of PHI necessary.

To Personal Representatives: We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law. We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative.

To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care. These disclosures may occur when you are not present, as long as you agree and do not express an objection. These disclosures may also occur if you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest. We may also disclose limited PHI to public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you. You have the right to limit or stop these disclosures.

YOUR RIGHTS CONCERNING PRIVACY

Access to Certain Records: You have the right to inspect and copy your PHI in a designated record set except where State law may prohibit client access. A designated record set contains medical and billing and case management information. If we do not have your PHI record set but know who does, we will inform you how to get it. If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them. If The Company produces copies for you, we may charge you up to $1.00 per page up to a maximum fee of $50.00. Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated by The Company.

Amendments to Certain Records: You have the right to request certain amendments to your PHI if, for example, you believe a mistake has been made, or a vital piece of information is missing. You must submit your request in writing to medicalrecords@trosthealth.com or via certified mail at the address listed herein. Verbal requests will cannot be processed. The Company is not required to make the requested amendments and will inform you in writing of our response to your request.

Request for Your Own Records: In accordance with 45 CFR §164.524 and program policy, you must submit a written request, and you may be asked to sign a release of information [for identification purposes] to access or obtain a copy of your own records. Initial written requests can be made to medicalrecords@trosthealth.com and [if determined necessary] a subsequent release of information will be sent to you. Verbal requests cannot be processed. You unequivocally understand and agree to this process and that verbal requests will not be processed and under reasonable circumstances an ROI will be asked to be going.

Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI that were made by The Company for a period of six (6) years prior to the date of your written request. This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order.

Restrictions: You have the right to request that we agree to restrictions on certain uses and disclosures of your PHI, but we are not required to agree to your request. You cannot place limits on uses and disclosures that we are legally required or allowed to make.

Revoke Authorizations: You have the right to revoke any authorizations you have provided, except to the extent that The Company has already relied upon the prior authorization.

Delivery by Alternate Means or Alternate Address: You have the right to request that we send your PHI by alternate means or to an alternate address.

Complaints & How to Contact Us: If you believe your privacy rights have been violated, you have the right to file a complaint by contacting The Company at the address indicated below. You also have the right to file a complaint with the Secretary of the United States Department of Health and Human services in Washington, D.C. The Company will not retaliate against you for filing a complaint. If you believe your privacy rights have been violated, you may make a complaint by contacting The Company Privacy Officer, HIPAA Privacy Officer, or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

Trost IN LLC

c/o Privacy Officer

120 N Federal Highway, Suite 206

Lake Worth, FL 33460

If you believe your privacy rights have been violated, you may make a complaint, in writing, by contacting The Company Privacy Officer, HIPAA Privacy Officer, or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

The U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

Toll Free: 1-877-696-6775

Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.

I acknowledge that I have received a copy of this notice regarding the use and disclosure of my health information.