THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

  1. OUR COMMITMENT TO YOUR PRIVACY

As a patient of LearnWell Behavioral Health, LLC d/b/a ilearn (“we,” “us,” “our,” or “ilearn”), you have legal rights concerning how we use or disclose medical information about you. We are required by the federal Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act, Public Law 111-005, and the regulations thereunder (“HIPAA”), and applicable Massachusetts state law to maintain the privacy of your protected health information (“PHI”) and provide you with this Notice of Privacy Practices (this “Notice”).

PHI is health information, including demographic information such as your name, address, telephone number, social security number, birth date, and gender, as well as past, present, or future information about your or your child’s physical, developmental or mental health condition, and information about the services provided to you, including payment information, if any of that information may be used to identify you.

This Notice describes how we may use and disclose your PHI to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by state and federal law. As required by law, this Notice describes:

  • How we may use and disclose your PHI;
  • Your privacy rights with respect to your PHI; and
  • Our obligations concerning the use and disclosure of your PHI.

The terms of this Notice apply to all records containing your PHI that are created or received by ilearn. We are required by law to abide by the terms of the notice of privacy practices currently in effect. We reserve the right to revise or amend this Notice. Any revision or amendment to this Notice will be effective for all of your records that we have created or received in the past, and for any of your records that we may create or receive in the future. We will post a copy of our current Notice on our website and in our office in a visible location at all times. You may request a copy of our most current Notice at any time by contacting our Privacy Officer. 

YOUR PRIVACY RIGHTS ARE IMPORTANT TO US. IF YOU HAVE QUESTIONS REGARDING THIS NOTICE OF PRIVACY PRACTICES OR OUR HEALTH INFORMATION PRIVACY POLICIES, PLEASE CONTACT OUR PRIVACY OFFICER AT ______. 

  1. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your PHI without your specific permission in the following circumstances:

  • Treatment. We may use and disclose your PHI to provide you with medical treatment or services, including your treatment options. For example, we will record your current health care information in a record so we can see your medical history, which may help with diagnosis and treatment. We may provide your health information to other health care providers, such as referring or specialist physicians to assist you in your treatment.
  • Payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover the treatment.
  • Health Care Operations. We may use and disclose your PHI to assist in the operation of ilearn. For example, we may use your PHI to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for ilearn.
  • Business Associates. We sometimes contract with third-party business associates for services. Examples include ______________.
  • Appointment Reminders. We may use and disclose your PHI to contact you to remind you about an appointment. You may request that we provide such reminders only in a certain way or only at a certain place. We will try to accommodate reasonable requests.
  • Release of Information to Family/Friends. We may disclose your PHI to a family member, close friend, or other person you identify, to the extent the information is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever it is reasonably practicable for us to do so. We will disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
  • Personal Representative. If you have a personal representative such as a legal guardian or an agent under a health care power of attorney, we will disclose PHI to that person as if that person were you. If you become deceased, we may disclose PHI to your personal representative.
  • Limited Data Set. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health, and health care operations.
  1. USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe special circumstances in which we may use or disclose your PHI without your authorization:

  • Disclosure Required by Law. We may disclose your PHI as required by federal, state, or local law.
  • Public Health Activities. We may disclose your PHI to public health authorities that are authorized by law to collect information, such as vital records like births and deaths.
  • Health Oversight Activities. We may disclose your PHI as part of health oversight activities as authorized by law. Examples of such activities may include investigations, inspections, audits, and surveys.
  • Lawsuits and Similar Proceedings. We may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.
  • Law Enforcement. We may release PHI if asked to do so by a law enforcement official under certain circumstances which include:
  • Disclosure about a crime victim when authorized by law;
  • Concerning a death we believe has resulted from criminal conduct when authorized or required by law;
  • Regarding criminal conduct at our offices; and
  • In response to a warrant, summons, court order or similar legal process.
  • Abuse, Neglect, and Domestic Violence. Your PHI may be disclosed to an appropriate government agency if there is a belief that a patient has been or is currently the victim of abuse, neglect, or domestic violence and you agree to the disclosure or it is required by law that we do so.
  • Deceased Patients. We may release PHI to a medical examiner, coroner or funeral director as required or authorized by law to enable them to carry out their lawful duties.
  • Organ and Tissue Donation. If you are an organ donor, we may release your PHI to organizations that handle organ, eye, or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation.
  • Research. We may use and disclose your PHI for research purposes when such use or disclosure is approved by an institutional review board or is for the purpose of preparing for research.
  • Serious Threats to Health or Safety. We may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  • Military. We may disclose your PHI if you are a member of the United States or foreign military forces (including veterans) and if required by the appropriate
  • Specialized Functions. We may disclose your PHI for specialized government functions such as intelligence and national security activities.
  • Workers’ Compensation. We may disclose your PHI to the extent authorized by and necessary to comply with laws relating to workers’ compensation and similar programs.
  1. Use and Disclosure of your PROTECTED HEALTH information That Require Your Authorization

The following uses and disclosures of your PHI can be made only with your written authorization:

  • Marketing. Uses and disclosures for marketing, except if the communication is in the form of a face-to-face communication to you or is to provide you with a promotional gift of nominal value.
  • Sale of Protected Health Information. Uses and disclosures which are a sale of protected health information.
  • Mental Health, HIV, and Substance Use Information. Certain uses and disclosures of mental health information, HIV information and substance use information.
  1. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding the PHI that we maintain about you:

  • Confidential Communications. You have the right to request that ilearn communicate with you about your health and related issues in a particular manner or at a certain location. The request must be made in writing to the Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. ilearn will accommodate all reasonable requests. You do not need to give a reason for your request.
  • Requesting Restrictions. You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment, or health care operations. If you paid out-of-pocket in full for a health care service or item provided by ilearn, you have the right to restrict disclosure of your PHI to your health plan for purposes of payment or health care operations, and we are required to honor this request. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. Except as noted above, we are not required to agree to your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

In order to request a restriction on our disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion the information you wish restricted, whether you are requesting to limit ilearn’s use, disclosure, or both, and to whom you want the limits to apply.

  • Inspection and Copies. You have the right to inspect and obtain an electronic or paper copy of your PHI that may be used to make decisions about you as required by State and Federal law. You must submit a request in writing to the Privacy Officer in order to inspect and/or obtain a copy of your PHI. The Practice may charge a reasonable, cost-based fee for the costs of copying, mailing, labor, and supplies associated with the request. We may deny the request under certain limited circumstances; however, you may request a review of the denial. We have up to 30 days to provide you your PHI.
  • Amendment. You have the right to ask us to amend your health information if you believe the health information is incorrect or incomplete as required by State and Federal law. Such right shall extend for as long as the health information is kept by or for ilearn. You must submit your request in writing to the Privacy Officer and provide a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing to the Privacy Officer.
  • Accounting of Disclosures. You have the right to request an “accounting of disclosures.” An accounting of disclosures is a list of certain disclosures ilearn has made of your PHI. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. All requests for accounting of disclosures must state the time period for the disclosures, which period may not extend beyond six (6) years from the date of disclosure for all disclosures that were not through an electronic health record and may not be longer than three (3) years from the date of disclosure for disclosures through an electronic health record for treatment, payment or health care operations and may not include dates before April 14, 2003. The first accounting requested in a 12-month period is free of charge, but ilearn may charge a reasonable, cost-based fee for additional accountings within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any cost.
  • Right to a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request. To request a paper copy of this Notice, please contact the Privacy Officer.
  • Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable law. Any authorization you provide us regarding the use and disclosure of your PHI may be revoked at any time, except to the extent we have already relied upon your authorization in making a disclosure. Requests to revoke your authorization must be made to the Privacy Officer in writing. Once an authorization is revoked, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note we are required to retain records of your care.
  • Right to Receive Notice of a Breach. If for any reason there is an unsecured breach of your PHI, we will utilize the contact information you have provided to notify you of the breach, as required by law. In addition, your PHI may be disclosed as part of the breach notification and reporting process.
  • Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. To file a complaint with us, contact the Privacy Officer at the address above. All complaints must be submitted in writing and should be submitted within one hundred eighty (180) days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website,hhs.gov/ocr/hipaa, for more information. You will not be penalized or retaliated against for filing a complaint.
  1. EFFECTIVE DATE OF NOTICE

This Notice was published and originally became effective on _______, 2024. This Notice was last updated on _______, 2024. Please note that changes in law affecting your privacy rights may take effect at different times. Please speak with the Privacy Officer if you have any questions.

  1. CONTACT

If you have a question, need more information about this Notice, or wish to file a complaint, please contact ilearn’s Privacy Officer at _________ or in writing at the address above.

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