Notice of Privacy Practices
SOS Environmental Health LLC, QRMDs Dr. Steven Powell, Medical Director
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.
Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information (“PHI”). We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information. Except in the situations set out in the below, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure as may be required upon us.
By Federal HIPAA law we must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time. Such changes will be posted to our website qrmds.com/hipaa as they may be revised from time to time.
If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at https://www.qrmds.com/hipaa. You also may ask for a copy of the Notice by emailing us at support@qrmds.com and asking us to e-mail you a copy or by asking for a copy at your next appointment.
Uses and Disclosures of Your Protected Health Information That Do Not Require Your Further Consent:
The following describes circumstances under which you have agreed to us disseminating your Protected Health Information in the following specific ways without further consent. By affirming this notice and signing below the specific ways in which we may give out your information without any further consent on your part being required, include those listed below. This is how we may use and disclose your Protected Health Information without prior permission which is granted herein:
For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care. For example, your information may be shared with people performing lab work or x-rays.
To obtain payment. We may disclose your health information in order to collect payment for your health care. For instance, we may release information to your insurance company.
For health care operations. We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide. We may disclose your information to students training with us. We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you. You approve us to contact you in any of the ways described in this agreement, however we are not limited from contacting you in other ways not explicitly described.
When required by law. We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies. For example, we may have to report abuse, neglect or certain physical injuries.
For public health activities. We are required to report your health information, specifically the outcome of your tests to the local health department and to government agencies to prevent or control disease or injury. We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety. We are required by the CDC to report all Covid 19 test results and will do so via our laboratory partner. You understand and consent to our laboratory providing the results of your testing to the CDC as required by law.
For health oversight activities. We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.
For activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial. We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.
For studies. In order to serve our patient community, we may use or disclose your health information in general for research purposes. Such information will be used only in general terms for research or potential research purposes only. We will never share your name or unique identifying aspects of your record, only in general terms for research purposes to better the common good.
To avert a threat to health or safety. In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.
For specific government functions. In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs, and for national security reasons.
For workers’ compensation purposes. We may disclose your health information to government authorities under workers’ compensation laws if requested by such authorities.
For fundraising purposes. We may use certain information (such as demographic information, dates of services, department of service, treating physicians, and outcomes) to assist us in our understanding and communications of our business performance in use in our fundraising efforts to investors. We will not however disclose any individual identifiable information of yours other than in general terms and specifically and explicitly for the purpose of illustrating in general how the Company performs and manages its care of its patients.
Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object
In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object. We are NOT requesting your approval for this at this time, nor do we currently plan on disclosing your information in the following ways as set forth below. The following are only listed to explain those ways in which you may wish us to communicate and/or it may at some future date become desirable to communicate your PHI. If that is the case you will be notified in advance and we will NOT disclose your information other than receiving your direct approval of the same:
In patient directories. Your name, location and general health condition may be listed in our patient directory for disclosure to callers or visitors who ask for you by name. Additionally, your religion may be shared with clergy, however only upon your request or direct approval.
To your family, friends or others involved in your care. We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition. We may release your health information to organizations handling disaster relief efforts. However only upon your request or direct approval
Should you wish to object at any time to these specific disclosures you may notify us at support@qrmds.com
Uses and Disclosures of Your Protected Health Information That Require Your Consent:
The following uses and disclosures of your Protected Health Information will be made only with your written permission which you hereby consent to by affirming this agreement. However you may withdraw from this consent without any, which you may withdraw at any time. Should you wish to withdraw at any time from this consent you may do so by writing to support@qrmds.com and make the subject line “I withdraw my consent”
For research purposes. In order to serve our patient community, we may want to use your health information in research studies. For example, researchers may want to see whether your treatment cured your illness. In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes. Completion of this form is completely voluntary and will have no effect on your treatment. Specifically information about the virus if contracted by you. By your signature below you allow us to share basic demographic information about you (such as age, race, general medical condition, symptoms, sex).
For marketing purposes. Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment. Additionally, without your permission we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.
Of psychotherapy notes. Should your care with QRMD’s include any psychotherapy visits, and if applicable, we will not use or disclose notes in which your doctor describes or analyzes a counseling session in which you participated unless, with your prior approval, the use or disclosure is for on-site/ telemedicine related student training of staff directly related to your care and/or for disclosure required by a court order, or for the sole use of the doctor who took the notes only.
For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.
Your Rights Regarding Your Protected Health Information:
You have the following rights related to your Protected Health Information:
To inspect and request a copy of your Protected Health Information. You may look at and obtain a copy of your Protected Health Information in most cases. You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information which you cannot access by law. If we use or maintain the requested information electronically, you may request that information in electronic format by writing to support@qrmds.com and requesting a “physical copy” of your consent form.
To request that we correct your Protected Health Information. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file. We may deny your request if we find that the file is correct and complete, not created by us, or not allowed to be disclosed. If we deny your request, we will explain our reasons for the denial and your rights to have the request and denial and your written response added to your file. If we approve your request, we will change the file, report that change to you, and tell others that need to know about the change in your file.
To request a restriction on the use or disclosure of your Protected Health Information. You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request. An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service. If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations. We cannot limit uses or disclosures that are required by law.
To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way. We must agree to your request as long as it is reasonably easy for us to do so.
To find out what disclosures have been made. You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years. We must respond to your request within sixty days of receiving it. We will only charge you for the list if you request more than one list per year. The list will not include disclosures made to you or for purposes of treatment, payment, health care operations if we do not use electronic health records, our patient directory, national security, law enforcement, and certain health oversight activities.
To receive notice if your records have been breached. Company will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you. We will review any suspected breach to determine the appropriate response under the circumstances.
Consent to be treated via telemedicine.
By affirming this agreement you hereby consent to the Company managing your care via our Telemedicine platform and communication methods. All such communication methods are in compliance with applicable current HIPAA guidelines which are performed by us. The term “Telemedicine” may be used and encompasses a possible multiple way in which we would use electronic communication to manage our business and your care. Your consent to our use of telemedicine, for this agreement, shall mean any and all means electronically we communicate with you regarding your interactions with our company and care. These methods could include, but are not limited to, SMS text messaging, Patient Portal secure communications, Video Visits, Chat bot visits. All such communications on our end will be within the current guidelines as applicable conforming to the Hipaa federal protected health guidelines.
However it should be understood and acknowledged that we make every reasonable effort to ensure that all of our communication platforms are secure, but cannot guarantee that by using Telemedicine platforms for both synchronous and asynchronous communications that security will be maintained. You agree and understand that these platforms have limitations and are subject to different conditions that would exist in face to face in person interactions. You agree that having the Company provide your care via these types of platforms is an acceptable standard of care and you accept this by engaging the Company despite the limitations that telemedicine intrinsically has. These limitations include, but are without limitation to, limitations in security, limitations in the quality of the image or the discernibility of the audio or video image, tendencies of delay, inability to understand or properly evaluate medical advice being given and/or the qualified medical professionals inability to properly diagnose and manage your care due to limitations in the telemedicine platforms themselves.
Currently Company ONLY manages care via Telemedicine platforms and I acknowledge and understand the benefits with the use of telemedicine, as well as its limitations whereas there can be no guarantee to the results of all treatments made through this medium. I understand the limitations with the use of telemedicine where it cannot be fully equal to face-to-face mode of treatment and such delays may incur due to possible cases of intermittent communication that may arise and which the telemedicine service provider is of no fault.
I understand that there are State as well as Federal laws that help protect my privacy by standardizing confidentiality and information security that apply to telehealth and telemedicine consultations such as HIPAA. However, in case my insurance needs access to my medical information, I hereby grant release of information requested to my insurance provider and/or its representatives. I understand that my participation is voluntary and I have the right to withhold, or withdraw my consent to the use of the telemedicine anytime. However if I withdraw my consent to Company for Company’s use of telemedicine, it will likely result in Company being unable to manage my care.
Consent to treatment, care and testing.
While Company does not intend to take over the role of your primary care physician for its physician assisted services, Company will assist you and guide you through your interactions and care in connection with services provided for or facilitated by Company. These include, but are without limitation to, physician assisted testing for various infectious diseases and cancer screening to name but a few. Company operates as a medical clinic. As such we have many different providers who may interact with you during your care and engagement of the Company. You understand that Company does NOT guarantee to connect you with a specific provider or qualified medical professional nor connect you with the same qualified medical professional during your interactions with Company. You acknowledge and accept this as a reasonable level of care as provided by the Company. If in the future we are able to offer the ability to specifically have your care managed by a specific qualified medical professional we will notify you of this ability and allow you to elect to choose this option if available. However we make no guarantee that this will be an available feature now or in the future.
By signing this form, I affirm my voluntary consent to this telemedicine engagement. I understand that each item above was explained to me. I was given the opportunity to ask my questions and the questions were answered accordingly and to my satisfaction.
Insurance assignment of all benefits to Company: I hereby agree and consent to an assignment of my insurance benefits for all services including, but without limitation to laboratory testing, doctor services, interactions, or simply in relation to care by Company to Company directly. This will be applicable for any and all services performed on behalf of Company and or its laboratory for my interactions with company and my insurance benefits in connection with my interaction and treatment
By affirming below I authorize Company to release any medical information to my health insurance carrier and/or its legitimate agents that are necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employer’s or group health insurance plan, directly to Company.
I hereby authorize photocopies of this form to be valid as the original.
Electronic Prescription Subscription service. I understand that the Company may, if in prescribing medication on my behalf, may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my Company providers and my pharmacy. I have been informed and understand that Company providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my Company providers to see this health information.
Indemnification and hold harmless agreement
by electronically agreeing to these terms and conditions as stated herein, i understand that it is my responsibility to accurately enter any and all information I provide in my communications and all data entry into any electronic web based forms I’m asked to complete. It is my sole and complete responsibility to accurately communicate and complete any and information to Company in order for Company to properly manage my testing and treatment if provided. My responsibilities include, but are without limitation to, scanning or entering the bar code of my test kit vial accurately and properly, following all instructions, filling out forms truthfully and accurately, giving proper information to any health care provider, as well as following all instructions on all printed materials provided to me on the webpages or inserts in the packaging.
I agree to release the Company and hold it harmless from any injury I may sustain which maybe physical, economic, or consequential damage or injury that is the result of my actions in connection with the test process. Including but without limitation to injuries sustained by me in self administering the test. Further I understand and acknowledge that the ability of Company to accurately report the results of my Covid test, is reliant upon my ability to follow directions as given and enter the data as needed into the web based form and accurately follow the instructions provided to collect my sample. I acknowledge that I understand that IF at any time I become unsure about what to enter or how to proceed it is my sole responsibility to stop and seek advise from Company or my test administrator and not to “guess” at an answer, but rather to get advice or ask questions about how to properly provide the data I’m being asked to provide. It is my sole responsibility therefore to ensure the integrity of the data commensurate with my personal circumstances is accurate and complete. Further, I agree to hold the Company harmless and indemnify Company from any and all damages sustained from my actions, or failures on my part to accurately provide the data, properly collect the test, and follow directions from the known, unknown, direct or consequential damages I or the Company may incur as a direct result of my failure to enter information properly, follow directions or collect and record my sample vial test kit. I acknowledge that any injury sustained by me or others as a result of my failure to follow the directions provided or accurately enter my information, is my responsibility and I hold the Company harmless and indemnify the Company from any actions
Declaration by me the patient under penalty of perjury
by agreeing to the terms and conditions under the policy I hereby declare under penalty of perjury that the information provided is accurate to my best knowledge as entered herein at the time entered.
How to Complain about Our Privacy Practices
If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you may file a complaint with our Privacy Officer by writing to SOS Environmental Health/QRMDs, 59 Estaban Drive, Camarillo CA 93010 or via electronic mail to support@qrmds.com
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.
We will take no action against you if you make a complaint to either or both of these persons.
How to Receive More Information About our Privacy Practices
If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, Michael Keane at support@qrmds.com
Effective Date
This Notice is effective on November 1, 2020