Sample PHR Mock Notice

Birch Health

Birch

Facts about your personal information

Health

Why do we provide you this information?
We provide this information because we want you to clearly understand Birch Health’s policies, practices, and
procedures for using, securing, and protecting the personal information in your PHR. The table below provides you
a snapshot. You can link to more detailed information by clicking on any of the areas below.

PHR Facts At-A-Glance

Our Practices

PHR Type

Provided by

Healthcare provider

Fee

None

You

Yes

Family and friends

With your permission

Healthcare providers

With your permission

Insurers

With your permission

Employers

No

Pharmacies

With your permission

Who can view
your personal
information?

T
F

Additional health programs and services With your permission

How may we use
your personal
information?

A
R

Birch Health

Yes

Others

Yes

For Birch Health’s business practices

Yes (You may not opt out.)

For marketing

Aggregate information only (You may opt out.)

For medical research

Aggregate information only (You may opt out.)

For selling to others

Aggregate information only (You may opt out.)

For legal reasons

Yes (You may not opt out.)

What are our
policies about
closing your PHR?

Ability to close PHR

Yes

Data retention by Birch Health

90 days

Ability to transfer to another PHR

Yes

When will you be
notified?

If Birch Health is sold/merged/out of
business

Yes

If there is a change in these policies

Yes

If there is a security breach

Yes

How do we store and
protect your personal
information?

Geographic location of data storage

USA only

Log of all PHR views for customer
review

Yes

Full printable version

http://www.BirchPHR.com/fullversion

Contact information

info@BirchPHR.com

D

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Disclaimer: “Birch Health” is a fictional company. This document is a preliminary draft that is under
development and provided solely for informational purposes. The information in this draft document may not
be complete, comprehensive, or represent all of the legal obligations with which an entity needs to comply.
Any reliance on the presentation or content provided in this document, in its current form, may pose legal risk.

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Birch Health

Birch

Facts about your personal information

Health

What is personal information?
You store personal information in your PHR as a way to help better manage your health. Personal
information is information about you that includes contact information, demographic information,
health information, and financial information. Examples are listed below:
Contact Information (e.g., for use in the event of an emergency or to speed up registering
with a new physician)
• name
• address
• email address
• phone number
• social security number
• emergency contact

T
F

Demographic Information (e.g., to inform your physician of potential risk factors)
• age
• gender
• ethnicity
• occupation

A
R

Health Information (e.g., to better manage a health condition)
• medical conditions
• medications (over-the-counter and prescription)
• lab/test results
• doctor’s contact information
• immunizations
• disease management charts
• injury management

D

Financial Information (e.g., to keep track of your health care expenses)
• healthcare bills
• health insurance
• healthcare savings account (HSA) information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

| Home | Terminology | Contact Us |

Page 2

Birch Health

Birch

Facts about your personal information

Health

What PHR type are we?
PHR Type

Birch Health is a Healthcare Provider. Knowing the PHR type we provide will
help you understand our policies, practices, and procedures.

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

PHR provided by

Description

Employer

Some large employers offer
PHRs as a feature of a benefits
plan. More...

Healthcare Provider

Some healthcare providers
offer PHRs as a way to
provide patients with health
information from the clinicians’
record. More...

Health Insurer
(PPO or HMO)

Some health insurers offer
PHRs to provide consumers
with information from health
insurance claims. More...

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

Independent

D

Full printable version

Do you
pay a
fee?

No

T
F

Some independent internet
companies offer PHRs
directly to consumers. Some
Employers, Healthcare
Providers, and Health Insurers
may also have partnerships
with independent internet PHR
companies. More...

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Birch Health

Birch

Facts about your personal information

Health

Who can view your personal information?
PHR Type

When you set up your PHR, you may be able to give permission to certain
people or groups to view some or all of your personal information.

Who can view your
personal information?

Can they view
information?

Can they add
information?

Can they edit
information?

You (PHR customer)

Yes

Yes

Yes, self-entered
information

Your family and
friends

With your
permission

With your
permission

With your
permission

Your healthcare
providers

With your
permission

With your
permission

No

Your health insurer

With your
permission

With your
permission

No

Your employer

No

No

No

Your pharmacy

With your
permission

No

Additional health
programs and
services

With your
permission

With your
permission

No

Birch Health and its
employees

Yes

No

No

Companies doing
work for Birch
Health to operate
and manage the
systems

Yes

No

Birch Health’s
business and
advertising partners

No

No

No

Law enforcement for When legally
legal investigations
required

No

No

Government for
national security

When legally
required

No

No

The public (through
chat rooms and
forums)

With your
permission

No

No

Your health partners

How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

D

Full printable version

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

Birch Health

T
F
No

No

Others

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Birch Health

Birch

Facts about your personal information

Health

Who can view your personal information?
PHR Type

When you set up your PHR, you may be able to give permission for certain
people or groups to view some or all of your personal information.

Who can view your
personal information?

Can they view
information?

Can they add
information?

Can they edit
information?

You (PHR customer)

Yes

Yes

Yes, self-entered
information

Your family and
friends

With your
permission

With your
permission

With your
permission

Your healthcare
providers

With your
permission

With your
permission

No

Your health insurer

With your
permission

With your
permission

No

Your employer

No

No

No

Your pharmacy

With your
permission

No

Additional health
programs and
services

With your
permission

With your
permission

No

Birch Health and its
employees

Yes

No

No

Companies doing
work for Birch
Health to operate
and manage the
systems

Yes

No

Birch Health’s
business and
advertising partners

No

No

No

Law enforcement for When legally
legal investigations
required

No

No

Government for
national security

When legally
required

No

No

The public (through
chat rooms and
forums)

With your
permission

No

No

Your health partners

How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

D

Full printable version

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

Birch Health

Duplicate
Page
with
Rollover

Some examples of
additional health
programs and services
that work with the PHR
include fitness activity
journals, weight loss
programs, and glucose
monitoring services.

T
F
No

No

Others

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Birch Health

Birch

Facts about your personal information

Health

How may we use your personal information?
PHR Type

Birch Health uses the personal information in your PHR for certain reasons.

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

Common uses of personal information
in a PHR

Does Birch
Health do this?

Can you
opt out?

Process exchanges between your PHR
and healthcare providers

Yes, with your
permission

Yes, you choose
sharing-levels.

Process exchanges between your PHR
and labs, pharmacists, health plans, etc.

Yes, with your
permission

Yes, you choose
sharing-levels.

Communicate with you

Yes

You may not
opt out.

Maintain and improve Birch Health’s PHR
systems

Yes

Manage Birch Health’s security systems
(such as against spam, misuse, and
criminal activity)

Yes

Birch Health’s marketing purposes – to
offer our health-related products and
services to you

Yes

Birch Health’s marketing purposes – to
offer our non-health-related products and
services to you

No

For you and your health needs

Birch Health’s everyday business practices

D

Full printable version

Contact information

A
R

T
F
You may not
opt out.
You may not
opt out.

You may opt out
by changing your
preferences.
N/A

Sharing and selling for marketing

Your personal information to our business
and advertising partners

No, we do not
share or sell

N/A

Anonymized information to our business
and advertising partners

Yes, we sell

You may opt out
by changing your
preferences.

Anonymized information for Birch Health
to market itself to business partners

Yes, we share

You may opt out
by changing your
preferences.

Your personal information for medical and
public health research

No, we do not sell
or share

N/A

Anonymized information for medical and
public health research

Yes, we share

You may opt out
by changing your
preferences.

Sharing and selling for medical research

Click here for more about our sharing and selling
Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

For legal reasons
Comply with subpoenas, court orders, and
Yes
search warrants

| Home | Terminology | Contact Us |

You may not
opt out.

Page 6

Birch Health

Birch

Facts about your personal information

Health

How may we use your personal information?
PHR Type

Birch Health uses the personal information in your PHR for certain reasons.

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

Common uses of personal information
in a PHR

Does Birch
Health do this?

Can you
opt out?

Process exchanges between your PHR
and healthcare providers

Yes, with your
permission

Yes, you choose
sharing-levels.

Process exchanges between your PHR
and labs, pharmacists, health plans, etc.

Yes, with your
permission

Yes, you choose
sharing-levels.

For you and your health needs

Birch Health’s everyday business practices
Communicate with you

Yes

Maintain and improve Birch Health’s PHR
systems

Yes

Manage Birch Health’s security systems
(such as against spam, misuse, and
criminal activity)

Yes

Birch Health’s marketing purposes – to
offer our health-related products and
services to you

Yes

Birch Health’s marketing purposes – to
offer our non-health-related products and
services to you

No

D

Full printable version

Contact information

A
R

You may not
opt out.

T
F
You may not
opt out.
You may not
opt out.

You may opt out
by changing your
preferences.
N/A

Sharing and selling for marketing

Anonymized information
does not include specific
contact information or other
information that may make it
easy to know who you are.

Your personal information to our business
and advertising partners

No, we do not
share or sell

N/A

Anonymized information to our business
and advertising partners

Yes, we sell

You may opt out
by changing your
preferences.

Anonymized information for Birch Health
to market itself to business partners

Yes, we share

You may opt out
by changing your
preferences.

Your personal information for medical and
public health research

No, we do not sell
or share

N/A

Anonymized information for medical and
public health research

Yes, we share

You may opt out
by changing your
preferences.

Sharing and selling for medical research

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

Duplicate
Page
with
Rollover

Birch Health only
shares or sells
anonymized
information...etc.

Click here for more about our sharing and selling
For legal reasons
Comply with subpoenas, court orders, and
Yes
search warrants

| Home | Terminology | Contact Us |

You may not
opt out.

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Birch Health

Birch

Facts about your personal information

Health

What are our policies about closing your PHR?
PHR Type

Birch Health has specific policies if you close your PHR.

Who can view your
personal information?

Common closing questions

Your options

Can you close your PHR?

Yes. You must
contact us.

How may we use your
personal information?

Is your personal information
permanently removed from Birch
Health’s systems?

Yes, after 90 days

What are our policies
about closing
your PHR?

How long does Birch Health keep
your personal information?

90 days

Will all authorized users’ access be
immediately terminated?

Yes. Here’s how.

Can you transfer your PHR data to
another PHR?

Yes. Here’s how.

When will you be
notified?
How do we store and
protect your personal
information?

D

Full printable version

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

| Home | Terminology | Contact Us |

T
F

Page 8

Birch Health

Birch

Facts about your personal information

Health

When will you be notified?
PHR Type

Birch Health contacts you by email for certain reasons.

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

Reasons you may
be notified

Can you
opt out?

Your options once
notified

Yes

You may not
opt out.

If you do not agree with the
changes, you have 10 days
to close your PHR.

If Birch Health is
sold, merges with
Yes
another company, or
goes out of business.

You may not
opt out.

Changes to Birch
Health’s policies,
practices, and
procedures

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

If you do not wish to remain
a customer, you must
contact us to close your
PHR.

T
F

Yes

You may not
opt out.

If you do not wish to remain
a customer, you must
contact us to close your
PHR.

Changes to PHR
services, such as
new features

Yes

You may not
opt out.

N/A

Changes to the
type of information
available to or
through your PHR

Yes

You may not
opt out.

N/A

Newsletters and
optional surveys

Yes

You may
opt out.

You may change your
preferences.

Marketing materials
from Birch Health
and associates

Yes

You may
opt out.

You may change your
preferences.

A
R

In the event of a
security breach

D

Full printable version

Will Birch
Health
notify
you?

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Page 9

Birch Health

Birch

Facts about your personal information

Health

How do we store and protect your personal
information?

PHR Type

Birch Health uses physical, technical, and procedural safeguards to protect your
personal information from unauthorized access or use.

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?

Common protections of online and
health information
Legal protections
HIPAA Privacy and Security Rules for health
information

Privacy certifications

{ List other privacy certifications it must follow in
additional rows.}

How do we store and
protect your personal
information?

Contact information

A
R

Computer network and data processing protections
Log of all PHR views (audit trail) for your review

D

Full printable version

As a Healthcare Provider PHR,
we are legally required to follow
the HIPAA Privacy and Security
Rules.

{List other laws it must follow in additional rows.}

CCHIT Certified status for health information
technology

When will you be
notified?

Does Birch Health do this?

T
F

Yes

Yes

All data processed in USA

Yes

User ID and password

Yes

Time-out your PHR access when your
computer is idle

Yes

Data storage protections

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

All data storage in USA

Yes

Geographically diverse data storage locations

Yes, in two corporate facilities
within the USA

Data storage power supply redundancy,
environmental controls, and a security system

Yes

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Page 10

Birch Health

Birch

Facts about your personal information

Health

Contact Information
PHR Type

Web: http://www.BirchPHR.com/contactform
Email: info@BirchPHR.com

Who can view your
personal information?

Privacy Officer: Birch Health Privacy Officer
Write: Birch Health, 123 Main St., Birch Park, MT 23456
Call:

1-800-XXX-XXXX

How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

D

Full printable version

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

| Home | Terminology | Contact Us |

T
F

Page 11

Birch Health

Birch

Facts about your personal information

Health

Terminology
PHR Type

Who can view your
personal information?
How may we use your
personal information?
What are our policies
about closing
your PHR?
When will you be
notified?
How do we store and
protect your personal
information?

D

Full printable version

Contact information

Disclaimer: “Birch Health” is a fictional
company. This document is a preliminary
draft that is under development and
provided solely for informational
purposes. The information in this
draft document may not be complete,
comprehensive, or represent all of the
legal obligations with which an entity
needs to comply. Any reliance on the
presentation or content provided in this
document, in its current form, may pose
legal risk.

A
R

| Home | Terminology | Contact Us |

T
F

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