A-WARE OF YOUR NEEDS, LLC NOTICE OF PRIVACY PRACTICES
(A-WARE of Your Needs, LLC Privacy Practice Notice Effective November 1, 2021)
Be advised to review the following information in its entirety. Within in this documentation you will be given disclosure in regards to how your medical and any other confidential information will be disclosed and utilized. This documentation will explain how you can access this information.
In receiving services from A-WARE of Your Needs, LLC and Health and Human Services (HHS) we will be recipients of, be able to create, and maintain your health information, treatments that you undergo, and payment for services. With the exception of what will be detailed in this notice, we will not disclose your information unless we have your written consent to disclose of your information. Your consent will then give us permission to disclose of your information.
Listed below is how we may utilize and disclose your health information (Please read in its entirety)
A-WARE of Your Needs, LLC may utilize and disclose your health information and confidential information (without your consent) regarding health care purposes, payment, and treatment.
Below are examples, but are not limited to:
· Utilizing or sharing your health information and confidential informationwith other health care providers who have involvement in your treatment, agencies that have involvement in your treatment, and pharmacies with whom your prescriptions are filled through.
· Utilizing or sharing your health information and confidential information with your health plan to obtain payment for services as well as utilizing your health information and confidential informationin determination of your eligibility for government benefits in a health plan.
· Utilizing or sharing your health information and confidential information to run A-WARE of Your Needs, LLC, to evaluate provider performance, to assist in educating other health care professionals, as well as for general administrative activities.
A-WARE of Your Needs, LLC may share your health information and confidential information with other business associates who are in need to utilize the information to perform services on the behalf of A-WARE of Your Needs, LLC and agree to protect the privacy and security of your health information and confidential informationin accordance to agency standards.
A-WARE of Your Needs, LLC may utilize or share your health information and confidential information without your consent as authorized by law for our patient directory, to your family or friends who have involvement in your care, or to a disaster relief agency for purposes of to notify your family or friends of your location and status update in time of an emergent situation.
A-WARE of Your Needs, LLC may utilize and disclose your health information and confidential informationwithout your consent to contact you regarding the following, as permitted by law and agency policy:
· To provide appointment reminders
· To describe or recommend treatment alternatives
· To provide information about health-related benefits and services that may be of your interest
· For fundraising purposes
A-WARE of Your Needs may utilize and disclose of your health information without your consent for the following purposes:
· Regarding public health activities including reporting diseases, injuries, births or deaths to an authorized public health agency, or to report medical device issues to the FDA
· To be compliant with workers compensation laws and programs of the like
· To notify appropriate authorities regarding victims of abuse, neglect, or domestic violence; in the situation that the agency reported to reasonably believes that you are a victim of abuse, neglect, or domestic violence, A-WARE of Your Needs, LLC will exhaust every effort to obtain your consent, however, in certain cases we may be required or authorized to alert authorities
· For health oversight cases such as audits, inspections of A-WARE of Your Needs, LLC facilities, and investigations
· For research purposes that are approved by an Institutional Review Board or privacy board, in regards to preparation for research such as formulating and writing a research proposal; or for research regarding descendants information
· In regards to share or create concealed or semi-concealed health information (limited data sets)
· In response to a subpoena or other law pertaining order regarding administrative or judiciary proceedings
· In regards to purposes pertaining identifying or locating a missing persons or suspect regarding law enforcement purposes
· Release of information to coroners, medical examiners, or funeral directors in accordance to what is needed pertaining to their jobs
· Release to organizations that handle organ, eye or tissue donation, transplant, or procurement
· In avoidance of a threat to health or the safety of the public
· In regards to specialized government functions i.e. veterans activities and military, national security and intelligence activities, or for other law enforcement supervisory situations
· For unintentional disclosures such as someone overhearing information although reasonable steps have been executed to maintain confidentiality of information
· As permitted or required by local, state, or federal law
In addition, privacy protections under federal and state law is applicable to substance abuse information, information regarding mental health, some disease-related information, or information regarding genetic. This information will only be shared as authorized by law. Disclosure of genetic information will not be utilized for underwriting purposes.
For notation we will always obtain your consent to utilize or share your information for marketing purposes, as well as to utilize your psychotherapy notes, if payment from a third party is needed, as well as regarding any disclosure not described in this Notice of Privacy Practices or required by law. You hold the right to cancel your consent, with exception to the extent to which we have take action based on your consent. To cancel your consent please notify the privacy office in writing per below.
Your Privacy Rights
You Have The Right To:
· Copy and inspect your health information, in inclusion of lab reports, some exceptions may apply.
· Receive communication of your health information within the records of A-WARE of Your Needs, LLC with regards to confidentiality. You will need to specify your preferred contact information so that we can contact you with this information, i.e. a certain address or telephone number. There may be a requirement for you to make your request in writing including an explanation for the request or a statement
· Request an account of certain disclosures of your health information that has been made on behalf of A-WARE of Your Needs, LLC that were without your consent.
· Request restriction in regards to how A-WARE of Your Needs, LLC disclose of your health information regarding treatment, payment, and other health care operations, as well as to your family or friends. Please note that A-WARE of Your Needs, LLC is not required to agree to your request
· To obtain a copy of this Notice of Privacy Practices upon your request
Please make any of the above requests to A-WARE of Your Needs, LLC P.O. Box 671474 Houston, TX 77267, Telephone: 713-632-2985, Email: awareofyourneeds@gmail.com
Texas Health and Human Services (Texas HHS) that A-WARE of Your Needs, LLC will have the right to create, receive, maintain, use, disclose or have access to the following in reference to your confidential information
· Health Insurance Portability and Accountability Act (HIPPA) data
· Criminal Justice Information Services (CIIS) data
· Internal Revenue Service Federal Tax Information (IRS FTI) data
· Centers for Medicare & Medicaid Services (CMS)
· Social Security Administration (SSA)
· Personally Identifiable Information (PII)
HIPPA & Privacy Practices (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
HHS agencies and divisions must protect client confidential information and respond appropriately to suspected or actual breaches. To safeguard private information and prevent breaches, HHS agencies and divisions must follow:
Federal and state privacy laws, such as HIPAA, the Texas Medical Records Privacy Act, and the Texas Identity Theft Enforcement and Protection Act.
Federal and state benefit requirements for Medicaid and other programs.
HHS policies, including those established by the HHS Privacy Division and HHS Information Security.
Privacy Rule(Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
HHS agencies and divisions must protect client confidential
The HIPAA privacy rule establishes national standards protecting medical records and other personal health information. The HIPAA privacy rule applies to:
Health plans
Health care clearinghouses
Health care providers conducting certain electronic health care transactions
Under this rule, HHS must protect the privacy of private health information and limit the use and disclosure of that information without the patient's permission. Patients have rights over their health information. They have the right to review and get a copy of their health records and the right to ask for corrections to their health information.
The Health Insurance Portability and Accountability Act of 1996 and the related regulations at 45 C.F.R. Parts 160 and 164, known collectively as HIPAA, establishes standards for the privacy and security of health information. It also has standards for protecting health information transmitted electronically.
HIPAA privacy requires us to give you a Notice of Privacy Practices. It will let you know how: HHS can use and share your protected health information. (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
HHS may need to get your permission before we can share your records. (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
HHS must protect the privacy of your health information. (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
You have the right to complain to HHS or the U.S. Department of Health and Human Services, Office for Civil Rights if you think your privacy rights have been violated. (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
You can contact HHS to get more information about privacy or to file a complaint. (Per https://www.hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws)
A-WARE of Your Needs, LLC Duties
A-WARE of Your Needs, LLC is required to provide you with notice of our privacy practices and legal obligations in reference to your health information. It is our obligation to maintain the privacy of information that is able to identify you as well as notify you if for any reason the confidentiality of your privacy of health information has been compromised.
A-WARE of Your Needs, LLC will conduct annual workforce training and monitoring for and correction of any training delinquencies.
A-WARE of Your Needs, LLC will provide the notice of privacy practice to you no later than the first date of service delivery, with the exception of you being in an emergent treatment situation. A-WARE of Your Needs, LLC will make effort to obtain your written acknowledgment of receipt of the notice. If written acknowledgment cannot be obtainedfrom you, A-WARE of Your Needs, LLC will document efforts to obtain the acknowledgment and the reason why it was not obtained.
A-WARE of Your Needs, LLC is obligated to follow the terms of this Notice of Privacy Practices. We do hold the right to make changes and revisions to this Notice of Privacy Practices in which will be effective for all health information that we maintain. We will update you with the revised Notice of Privacy Practices no later than 60 days from the date that the revision was completed. You may also request any revised copy at any time as well by requesting from A-WARE of Your Needs, LLC contact listed at A-WARE of Your Needs, LLC P.O. Box 671474 Houston, TX 77267, Telephone: 713-632-2985, Email: awareofyourneeds@gmail.com
A-WARE of Your Needs, LLC will not retaliate against you for exercising your rights provided by the Privacy Rule, for assisting in an investigation by HHS or another appropriate authority. A-WARE of Your Needs, LLC will not retaliate against you for opposing an act or practice that you believe in good faith violates the Privacy Rule. A-WARE of Your Needs, LLC will not require you to waive any right under the Privacy Rule as a condition for obtaining treatment, payment, and enrollment or benefits eligibility.
A-WARE of Your Needs, LLC will conduct annual workforce training and monitoring for and correction of any training delinquencies.
A-WARE of Your Needs, LLC prohibits disclosure of A-WARE of Your Needs, LLC work product done on behalf of Texas HHS pursuant to the Data Use Agreement (DUA), or to publish Texas HHS Confidential Information without express prior approval of the Texas HHS agency.
Personal Representative
The Privacy Rule requires A-WARE of Your Needs, LLC to treat a "personal representative" the same as the individual receiving services through A-WARE of Your Needs, LLC, in regards to disclosures and uses of your protected health information, as well as your rights under the Rule.84 A personal representative is defined as a person legally authorized to make health care decisions on an your behalf or to act for a deceased individual or the estate. The Privacy Rule permits an exception when A-WARE of Your Needs, LLC has a reasonable belief that the personal representative may be neglecting or inflicting abuse onyou, or that treating the personal representative as you could otherwise endanger you.
Minors
In most cases, parents are the personal representatives for their children who are minors. In most cases, parents can exercise their individual rights, such as accessing their minor children’smedical record. There are exceptional cases where the parent is not considered the minor’s personal representative. In such cases, the Privacy Rule defers to State and other law to determine the rights of parents to access and control the protected health information of their minor child. If State and other law is silent concerning parental access to the minor’s protected
health information, A-WARE of Your Needs, LLC has discretion to provide or deny a parent access to the minor’s health information, this is provided that the decision is made by a licensed health care professional in the exercise of professional judgment.
ARTICLE 4. BREACH NOTICE, REPORTING AND CORRECTION REQUIREMENTS
Section 4.01. Breach or Event Notification to HHS. 45 CFR 164.400-414
(A) CONTRACTOR will cooperate fully with HHS in investigating, mitigating to the extent
practicable and issuing notifications directed by HHS, for any Event or Breach of Confidential
Information to the extent and in the manner determined by HHS.
(B) CONTRACTOR’S obligation begins at the Discovery of an Event or Breach and
continues as long as related activity continues, until all effects of the Event are mitigated to
HHS’s satisfaction (the "incident response period"). 45 CFR 164.404
(C) Breach Notice:
1. Initial Notice.
a. For federal information, including without limitation, Federal Tax Information, Social Security
Administration Data, and Medicaid Client Information, within the first, consecutive clock hour
of Discovery, and for all other types of Confidential Information not more than 24 hours after
Discovery, or in a timeframe otherwise approved by HHS in writing, initially report to HHS's
Privacy and Security Officers via email at: privacy@HHSC.state.tx.us and to the HHS division
responsible for this DUA; and IRS Publication 1075; Privacy Act of 1974, as amended by the
Computer Matching and Privacy Protection Act of 1988, 5 U.S.C. § 552a; OMB Memorandum
07-16 as cited in HHSC-CMS Contracts for information exchange.
HHS Contract No. ____
HHS Data Use Agreement V.8.3 April 1, 2015
Page 7 of 11
b. Report all information reasonably available to CONTRACTOR about the Event or Breach of
the privacy or security of Confidential Information. 45 CFR 164.410
c. Name, and provide contact information to HHS for, CONTRACTOR's single point of contact
who will communicate with HHS both on and off business hours during the incident response
period.
2. 48-Hour Formal Notice. No later than 48 consecutive clock hours after Discovery, or a
time within which Discovery reasonably should have been made by CONTRACTOR of an Event
or Breach of Confidential Information, provide formal notification to the State, including all
reasonably available information about the Event or Breach, and CONTRACTOR's investigation,
including without limitation and to the extent available: For (a) - (m) below: 45 CFR 164.400-
414
a. The date the Event or Breach occurred;
b. The date of CONTRACTOR's and, if applicable, Subcontractor's Discovery;
c. A brief description of the Event or Breach; including how it occurred and who is responsible
(or hypotheses, if not yet determined);
d. A brief description of CONTRACTOR's investigation and the status of the investigation;
e. A description of the types and amount of Confidential Information involved;
f. Identification of and number of all Individuals reasonably believed to be affected, including
first and last name of the individual and if applicable the, Legally authorized representative, last
known address, age, telephone number, and email address if it is a preferred contact method, to
the extent known or can be reasonably determined by CONTRACTOR at that time;
g. CONTRACTOR’s initial risk assessment of the Event or Breach demonstrating whether
individual or other notices are required by applicable law or this DUA for HHS approval,
including an analysis of whether there is a low probability of compromise of the Confidential
Information or whether any legal exceptions to notification apply;
h. CONTRACTOR's recommendation for HHS’s approval as to the steps Individuals and/or
CONTRACTOR on behalf of Individuals, should take to protect the Individuals from potential
harm, including without limitation CONTRACTOR’s provision of notifications, credit protection,
claims monitoring, and any specific protections for a Legally Authorized Representative to take
on behalf of an Individual with special capacity or circumstances;
i. The steps CONTRACTOR has taken to mitigate the harm or potential harm caused (including
without limitation the provision of sufficient resources to mitigate);
j. The steps CONTRACTOR has taken, or will take, to prevent or reduce the likelihood of
recurrence of a similar Event or Breach;
k. Identify, describe or estimate of the Persons, Workforce, Subcontractor, or Individuals and any
law enforcement that may be involved in the Event or Breach;
l. A reasonable schedule for CONTRACTOR to provide regular updates to the foregoing in the
future for response to the Event or Breach, but no less than every three (3) business days or as
otherwise directed by HHS, including information about risk estimations, reporting, notification,
if any, mitigation, corrective action, root cause analysis and when such activities are expected to
be completed; and
m. Any reasonably available, pertinent information, documents or reports related to an Event or
Breach that HHS requests following Discovery.
HHS Contract No. ____
HHS Data Use Agreement V.8.3 April 1, 2015
Page 8 of 11
Section 4.02 Investigation, Response and Mitigation. For A-F below: 45 CFR 164.308, 310
and 312; 164.530
(A) CONTRACTOR will immediately conduct a full and complete investigation, respond to
the Event or Breach, commit necessary and appropriate staff and resources to expeditiously
respond, and report as required to and by HHS for incident response purposes and for purposes of
HHS’s compliance with report and notification requirements, to the satisfaction of HHS.
(B) CONTRACTOR will complete or participate in a risk assessment as directed by HHS
following an Event or Breach, and provide the final assessment, corrective actions and
mitigations to HHS for review and approval.
(C) CONTRACTOR will fully cooperate with HHS to respond to inquiries and/or
proceedings by state and federal authorities, Persons and/or Individuals about the Event or
Breach.
(D) CONTRACTOR will fully cooperate with HHS's efforts to seek appropriate injunctive
relief or otherwise prevent or curtail such Event or Breach, or to recover or protect any
Confidential Information, including complying with reasonable corrective action or measures, as
specified by HHS in a Corrective Action Plan if directed by HHS under the Base Contract.
Section 4.03 Breach Notification to Individuals and Reporting to Authorities. Tex. Bus. &
Comm. Code §521.053; 45 CFR 164.404 (Individuals), 164.406 (Media); 164.408 (Authorities)
(A) HHS may direct CONTRACTOR to provide Breach notification to Individuals,
regulators or third-parties, as specified by HHS following a Breach.
(B) CONTRACTOR must obtain HHS’s prior written approval of the time, manner and
content of any notification to Individuals, regulators or third-parties, or any notice required by
other state or federal authorities. Notice letters will be in CONTRACTOR's name and on
CONTRACTOR's letterhead, unless otherwise directed by HHS, and will contain contact
information, including the name and title of CONTRACTOR's representative, an email address
and a toll-free telephone number, for the Individual to obtain additional information.
(C) CONTRACTOR will provide HHS with copies of distributed and approved
communications.
(D) CONTRACTOR will have the burden of demonstrating to the satisfaction of HHS that
any notification required by HHS was timely made. If there are delays outside of
CONTRACTOR's control, CONTRACTOR will provide written documentation of the reasons
for the delay.
(E) If HHS delegates notice requirements to CONTRACTOR, HHS shall, in the time and
manner reasonably requested by CONTRACTOR, cooperate and assist with CONTRACTOR’s
information requests in order to make such notifications and reports.
Complaints
If you believe that your rights have been violated you may file a complaint by contacting: DSHS Consumer Services and Rights Protection/Ombudsman Office by mail at Mail Code 2019, P.O. Box 149347 Austin, TX 78714-9347, or by telephone at (512) 206-5760 or (800) 252-8154 (toll free); and Office for Civil Rights, Region VI, U.S. Department of Health and Human Services, by mail 1301 Young St, Suite 1169, Dallas, TX 75202; or by telephone at (800) 368-1019, (214) 767-0432 (fax), or (800) 537-7697 (TDD)
Health and Human Services HHS
Email: privacy@hhsc.state.tx.us
Telephone: 877-378-9869 (toll-free)