Notice of Privacy Practices

Effective Date: February 11, 2016

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 the FirstLine Diagnostic of California, Inc. ("FLD") Privacy Officer at 415-834-5364 or by mail at 645 7th Street, San Francisco 94103.

WHAT IS THIS NOTICE AND WHO WILL FOLLOW THIS NOTICE?

This notice describes how we use and disclose health-related information about you (our “privacy practices”), including the practices of our employees and of third parties that handle your information when they provide certain services to us as our business associates.

OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that health information about you is personal and sensitive to you. We are committed to protecting the health information that we maintain about you.

We create a detailed record of the care and services you receive from us. 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 provided by your FirstLine health care providers, who may be physicians, physician assistants, registered nurses, or technicians, as well as third parties that work with us in connection with the services we provide to you. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to: make sure that health information that identifies you is kept private (with certain exceptions); give you this notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

The following categories describe different ways that we use and disclose your health information. For each category of uses or disclosures we have provides some examples, but not every possible use or disclosure in a category is listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to the FirstLine Privacy Officer.

DISCLOSURE AT YOUR REQUEST

We may disclose information when requested by you. This disclosure at your request may require a written authorization by you or your personal representative.

FOR TREATMENT

We may use health information about you to provide you with treatment or services. We may disclose health information about you to doctors, nurses, technicians, health care students, or other personnel who are involved in your care. We also may disclose health information about you to people outside of FirstLine who may are be involved in your medical care, such as your other health care providers, who need the information to provide you with medical care.

FOR PAYMENT

We may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you or a third party. For example, we may need to give information about services you receive to our administrative services providers in order to prepare invoices that are sent to you.

FOR HEALTH CARE OPERATIONS

We may use and disclose health information about you for a range of activities called health care operations. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the health information we have with health information from other health care providers to evaluate and compare how we provide services and to make improvements in the care and services we offer. We may remove information that identifies you from this information so others may use it to study health care and health care delivery without knowing the identities of specific patients.

APPOINTMENT REMINDERS

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

MARKETING AND SALE

Most uses and disclosures of health information for marketing purposes, and disclosures that constitute a sale of health information, require your authorization.

PSYCHOTHERAPY NOTES

Although our services generally do not involve the creation, maintenance, or disclosure of psychotherapy notes, most uses and disclosures of psychotherapy notes require your written authorization.

TO INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE

We may release health information about you to a friend or family member who is involved in your care. We may also give information to someone who helps to pay for your care. Unless there is a specific written request from you, we may also tell your family or friends limited information about your condition. In addition, we may disclose health information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If we determine that you are unconscious or otherwise unable to communicate, we may contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).

FOR RESEARCH

Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information in order to balance the research needs with the privacy of health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may disclose health information about you to the people who are conducting preparatory work relating to a research project.

SPECIAL SITUATIONS:

AS REQUIRED BY LAW

We will disclose health information about you when required to do so by international, federal, state or local law.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY

We may use and disclose health 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 someone able to help prevent the threat.

TO A HEALTH INFORMATION EXCHANGE

We may share electronic health information about you with a health information exchange in which we participate. Generally, a health information exchange is an organization with which regional health care providers participate for the purpose of exchanging electronic medical information with other health care providers who have a treatment relationship with you in order to facilitate health care, avoid duplication of services (such as diagnostic tests), and to reduce the likelihood of medical errors. A health information exchange is a business associate acting on our behalf, and on behalf of the other health care providers, and will receive, store or transmit electronic health information about you for treatment, payment, and health care operations purposes. The health information exchange is required to protect the confidentiality of the electronic health information. The electronic health information about you that we may disclose to a health information exchange may include sensitive diagnoses such as HIV/AIDS, sexually transmitted diseases, genetic information, and mental health substance abuse, etc. California law applicable to the exchange of electronic health information about you may require us to get your consent for such an exchange, or give you the right to revoke or restrict such consent. For more information please contact the FirstLine Privacy Officer using the contact information provided below.

ORGAN AND TISSUE DONATION

We may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

MILITARY AND VETERANS

If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

WORKERS’ COMPENSATION

We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

PUBLIC HEALTH ACTIVITIES

We may disclose health information about you for public health activities. These activities generally include disclosures to: prevent or control disease, injury or disability; report births and deaths; report regarding the abuse or neglect of children, elders and dependent adults; report reactions to medications or problems with products; notify people of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence (we will only make this disclosure if you agree or when required or authorized by law); notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

HEALTH OVERSIGHT ACTIVITIES

We may disclose health 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.

LAWSUITS AND DISPUTES

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

LAW ENFORCEMENT

We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct in or relating to the FirstLine practice; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES

We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS

We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

INMATES OR INDIVIDUALS IN CUSTODY

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official. This disclosure could be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.

BUSINESS ASSOCIATES

We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

MULTIDISCIPLINARY PERSONNEL TEAMS

We may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.

DATA BREACH NOTIFICATION PURPOSES

We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

DISASTER RELIEF

We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

SPECIAL CATEGORIES OF INFORMATION

In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information (e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse). Federal or state government health benefit programs may also limit the disclosure of beneficiary information for purposes unrelated to the program.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding health information we maintain about you.

RIGHT TO INSPECT AND COPY HEALTH INFORMATION

You (or your personal representative) have the right to inspect and obtain a copy of health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may be require to exclude some mental health information. To inspect and obtain a copy of health information that may be used to make decisions about you, you must submit your request in writing to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103. If you request a copy of the information, we have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and obtain a copy in certain limited circumstances. If you are denied access to your health information, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

RIGHT TO AN ELECTRONIC COPY OF ELECTRONIC MEDICAL RECORDS

If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

RIGHT TO GET NOTICE OF BREACH

You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

RIGHT TO AMEND HEALTH INFORMATION

If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for FirstLine. To request an amendment, your request must be made in writing and submitted to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103 You must provide specific reasons that supports your request. We may deny your request for an amendment 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 health information kept by or for FirstLine; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. If we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your health record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an accounting of certain disclosures that we make of your health information. This is a list of the disclosures we made of health information about you other than our own uses for treatment, payment and health care operations (as those functions are described above), and with other exceptions as provided by law. To request this accounting of disclosures, you must submit your request in writing to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103. Your request must state a time period to be covered by the accounting, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will notify you as required by law following a breach of your unsecured protected health information.

RIGHT TO REQUEST RESTRICTIONS

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a diagnosis that you receive. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

We are not required to agree to your request, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for purposes of providing treatment to you. If we agree to another special restriction, we will comply with your request unless the information is needed to provide you emergency treatment. To request these restrictions, you must make your request in writing to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103. In your request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, such as, for example, disclosures to your spouse.

OUT OF POCKET PAYMENTS

If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS

You have the right to request that we communicate with you about health 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 in writing to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103. 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 the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to request and receive a paper copy of this notice. You may obtain a copy of this notice at our website: firstlineapp.com/hipaa. To obtain a paper copy of this notice send a written request to the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103.

MORE STRINGENT STATE AND FEDERAL LAW

Whenever an applicable California law or a federal law provides for more protection of the confidentiality of health information about you, or for you to have more access to or control of medical information about you, we will comply with that more stringent law.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office, on our website, and on any telemedicine platform through which we provide services. The notice will contain the effective date of the notice. In addition, each time you initiate a session, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. To file a complaint with us, you may contact the FirstLine Privacy Officer at 645 7th Street, San Francisco 94103. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your health information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

QUESTIONS?

You may contact the FirstLine Privacy Officer:
By mail at 645 7th Street, San Francisco 94103
By telephone at 415-834-5364 or
By email at support@firstlineapp.com.

Please note that some requests described in this Notice must be requested in writing by mail.