Attachment_G-2_Health_Screening_Forms_HIPAA_Privacy_Practices

HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU

The following categories describe different ways that we use
and disclose medical information. For each category of uses or
disclosures we will explain what we mean and try to give some
examples. Not every use or disclosure in a category will be
listed. However, all of the ways we are permitted to use and
disclose information will fall within one of the categories.
For Services: We may use medical information about you to
provide you with health management services. We may
disclose medical information about you to healthcare providers
who are involved in taking care of you. For example, different
departments or sites also may share medical information about
you in order to coordinate the different services you need. We
may also disclose medical information about you to people
outside Viridian Health Management who may be involved in
your continued care, such as a disease management or
maternity management program.
Appointment Reminders: We may use and disclose medical
information to contact you as a reminder that you have an
appointment for care.
Preventative Health: We may use and disclose medical
information to tell you about changes or lifestyle options or
alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and
disclose medical information to tell you about health-related
benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment of Your Care:
We may release medical information about you to a friend or
family member that you indicate is involved in your care
unless you object in whole or in part.
As Required by Law: We will disclose medical information
about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety: We may use
and disclose medical 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. Any disclosure,
however would only be to help prevent the threat.

SPECIAL SITUATIONS
Military and Veterans: If you a member of the Armed Forces,
we may release medical information about you as required by
military command authorities. We may also release

information about foreign military personnel to the appropriate
foreign military authority.
Workers’ Compensation: We may release medical information
about you for Workers’ Compensation or similar programs.
These programs provide benefits for work-related injuries or
illness.

Patient Under Custody of Law Enforcement: If you are under
the custody of a law enforcement official we may release
medical information about you to the law enforcement official.
This release would be necessary for the institution to provide
you with the health care and/or to protect your health and
safety or the health and safety of others.

YOUR RIGHTS REGARDING MEDICAL INFORMATION
Public Health Risks: We may disclose medical information
about you for public health activities. These activities
generally include the following: to prevent or control disease,
injury or disability; to report births; to report child or elder
abuse; to report reactions to medication or problems with
products; to notify people of recalls of products that they may
be using; to notify a person who may have been exposed to a
disease or may be at risk for contracting or spreading a disease
or condition.
Health Oversight Activities: We may disclose medical
information to a health oversight agency for activities
authorized by law. These oversight activities include, for
example, audits, investigations, inspections and licensure.
These activities are necessary for the government to monitor
the health care system, government programs and compliance
with civil rights laws. We have an obligation to notify the
appropriate government authority if we believe a patient has
been a victim of abuse, neglect or domestic violence. We will
only make this disclosure if you agree or when required or
authorized by law.
Lawsuits and Disputes: If you are involved in a lawsuit or
dispute, we may disclose medical information about you in
response to a court or administrative order. We may also
disclose medical information about you to comply with a
subpoena, court order or other lawful process by someone
involved in the dispute, provided that the request meets all of
the legal requirements and is valid.
Law Enforcement: We may release medical information if
asked to do so by a law enforcement official: in response to a
court order, subpoena, warrant, summons or similar process; to
identify or locate a suspect, fugitive, material witness or
missing person; about a victim of a crime; about criminal
conduct at the center; and in certain circumstances to report a
crime; the location of a crime or victims; or the identity,
description or location of the person who committed the crime.
National Security and Intelligence Activities: We may release
medical information about you to authorized federal officials
for intelligence, counterintelligence and other national security
activities authorized by law.

ABOUT YOU

Right to Inspect and Copy: You have the right to inspect and
have copied information that is considered part of your
medical and billing records that may be used to make decisions
about your care. To inspect and have copied medical
information about you, you must submit your request in
writing to the Viridian Health Management Privacy Officer. 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. In certain circumstances, if you are denied access
to your information, you may request that the denial be
reviewed. Another licensed health care professional chosen by
Viridian Health Management will review your request and the
denial. The person conducting the review will not be the
person who denied your request. We will comply with the
outcome of the review.
Denial to Inspect and Copy: A patient does not have a right to
inspect or obtain a copy of consultation or psychotherapy
notes. A patient may not request a review of an originator’s
denial of access to consultation or psychotherapy notes.
However, a patient may be provided access to a summary of
the psychotherapy treatment.
Right to Correct or Update: For as long as your medical
information is kept by Viridian Health Management you have
a right to request a correction if you feel that this information
is incorrect or incomplete. To request a correction or update,
your request must be in writing with a reason to support the
request. We will respond within 60 days of receiving your
written request. We may deny your request if it is not in
writing or does not include a reason to support the request. 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 information kept by or
for Viridian Health Management; is not part of the information
which you would be permitted to inspect and have copied or is
accurate and complete. Any agreed upon correction will be
included as an addition to, and not a replacement of, already
existing records.

Right to a List of Disclosures We Have Made About You:
You have a right to request an accounting of the disclosures
we have made of your medical and billing information except
for disclosures made for treatment, payment and health care
operation as defined above. We are not obligated to list all
disclosures made about you. To request this list of disclosures,
you must submit your request in writing. Your request must
state a time period, which may not be longer that six years and
may not include dates before January 1, 2005. Your request
should indicate in what form you want the list (for example, on
paper, electronically). The first list you request within a 12month period will be free. For additional lists, we may charge
you for the costs of providing the list. We will notify you of
the costs involved and you may alter your request before any
costs are incurred.
Right to Request Restrictions: You have the right to request a
restriction or limitation on the medical and billing we use or
disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the
medical information we disclose about you to someone who is
involved in your care or payment for your care, like a family
member or friend. For example, you could ask that we not use
or disclose information about an evaluation you had. We are
not required to agree to your request. To request restrictions
regarding your care, you must make your restriction known at
the time of your registration. Any other restrictions must be in
writing. In your request, you must tell us 1) what information
you may want to limit; 2) whether you want to limit our use,
disclosure or both; and 3) to whom you want the limits to
apply, for example, disclosures to your spouse or insurance
company. A request to restrict information to your insurance
company will make you responsible for all fees associated
with your treatment.
Right to 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 at
the time of registration. We will not ask you the reason for
your request. We will accommodate all reasonable requests.
Your request must specify how or where you wish to be
contacted.
Right to a Paper Copy of This Notice: You have a right to a
paper copy of this notice. You may ask us to give you a copy
of this notice at any time. You may obtain a copy of this notice
at our website:

www.viridianhealth.com

You may receive a copy of this notice at any location where
you receive services. We will ask that you acknowledge
receipt of this notice in writing.
Changes to This Notice: We reserve the right to change the
terms of this notice and make revised or changed notice
effective for medical information we maintain. We will post
copies of the current notice in all locations where you receive
care. The effective date of the notice is contained on the first
page. In addition, each time you register at the center for
health care services we will offer you a copy of the current
notice in effect.
Complaints: You will not be penalized for filing a complaint.
If you believe your privacy rights have been violated, you may
file a complaint with Viridian Health Management or the
Secretary of the Federal Department of Health and Human
Services.
To file a complaint with Viridian Health Management, contact:

Privacy Officer, Viridian Health Management
22601 N. 19th Ave., Suite 240
Phoenix, AZ 85027
602-443-5260
or, The Secretary of the Federal Department of Health and
Human Services at:
Region VI, Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
Voice phone (214) 787-4056,
Fax (214) 767-0432
TDD (214) 767-8940.
Other Uses of Medical Information: Other uses of medical
information not covered by this notice or the laws that apply to
us will be made only with your written authorization. If you
provide us authorization to use or disclose medical information
about you, you may revoke it, in writing, at any time. If you
revoke it, we will no longer use or disclose medical
information about you or the reasons covered by your written
authorization, unless required by law. You understand that we
are unable to take back any disclosures we have already made
with your authorization and that we are required to retain our
records of the care that we provide to you.

Viridian Health Management
NOTICE OF PRIVACY PRACTICES
Effective Date: January 1, 2005
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

If you have any questions about this notice, please contact:
Privacy Officer, Viridian Health Management
22601 N. 19th Ave., Suite 240
Phoenix, AZ 85027
602-443-5260
Who Will Follow This Notice: This notice describes the
practices of Viridian Health Management.
Our Pledge Regarding Medical Information:
We understand that medical information about you and your
health is personal. We are committed to protecting medical
information about you. We create a record of services you
receive through Viridian Health Management. We need this
record to provide you with quality care and to comply with
certain legal requirements. This notice applies to all of the
records of your care generated by Viridian Health
Management. Non Viridian Health Management providers
may have different policies or notices regarding their use and
disclosure of your medical information created by their
providers.
This notice will tell you about the ways in which we may use
and disclose medical information about you. We also describe
your rights and certain obligations we have regarding the use
and disclosure of this medical information.
We are required by law to:
•
Make sure that medical information that
identifies you is kept private.
•
Notify you of our legal duties and privacy practices with
respect to medical information about you.
•
Follow the terms of the notice that is currently in effect.