AGAPE THERAPY
NOTICE OF PRIVACY PRACTICES
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.
Our Legal Duty
We are required by law to protect the privacy of your health information. We are also required to
provide you with notice of our legal duties, privacy practices, and your rights concerning your
protected health information. We are required to follow the privacy practices that are described
in this notice while it is in effect.
The effective date of this notice is: April 14, 2003 and will remain in effect until we replace it.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
We collect health information from you and store it on printed-paper and on electronic computer
systems. The collection of health information is considered your medical record. The medical
record is the property of Agape Therapy, but the information within the medical record
containing information about you belongs to you. We will use and disclose the protected health
information about you for treatment, payment, and health care operations.
Treatment: We will use and disclose your protected health information to provide, coordinate,
and manage your health care. We may disclose information to other providers involved in your
care. For example, we would disclose your protected health information, as necessary, to a home
health agency, pharmacist, supplier of medical equipment, as well as your physician or nurse to
discuss your plan of care.
Payment: We will use your protected health information, as needed, to obtain payment for your
health care services. We will disclose your health information to an insurance or managed care
company, Medicare, Medicaid, other third party payer, to assist in determining eligibility for
insurance benefits, and reviewing services provided to you for protected health necessity. We
will, for example, contact your health plan or Medicare to confirm your coverage or request prior
approval for services that will be provided to you.
Health Care Operations: We may use and disclose, as needed, your protected health
information in order to conduct certain business and health care operational activities. These
activities may include, but are not limited to, management of operations, personnel evaluations,
education and training of staff or students, quality of care assessment, and licensing and
credentialing activities. For example, we may call you by name in the waiting area when your
therapist is ready to see you. We may also discuss your treatment with you if you are in the
common gym area, although we will try to minimize others from overhearing by speaking in
lower tones. We may also use or disclose your protected health information, as necessary, to call
you on the telephone to remind you of your appointment. We may share your health information
with various third party “business associates” that provide various activities for our business.
When your health information is shared, we will have a written contract with that business
associate that contains terms that will protect the privacy of your health information.
Uses and Disclosures With Your Authorization
Except as described in this Notice of Privacy Practices, we will not use or disclose your health
information without your written authorization. If you authorize us to use or disclose your health
information for another purpose, you may revoke your authorization in writing at any time. Your
revocation will not affect any use or disclosure permitted by your authorization while it was in
effect. Without your written authorization, we will not use or disclose your health information
for any reason except those described in this notice.
Specific Uses and Disclosures of Your Health Information
The following are various ways that we may use or disclose your health information.
Individuals Involved in Your Care: Unless you object, we may disclose to a family member,
close friend or other person you identify, your protected health information that directly relates to
that person’s involvement in your health care. If you are unable to agree to or object to such a
disclosure, we may disclose such information as necessary if we determine, based on our
professional judgment, that it is in your best interests. We may use or disclose your health
information to notify or assist in the notification of a family member, your personal representative
or another person responsible for your care, of your location, general condition, or death.
As Required by Law: We may use or disclose your health information when required by law to
do so.
Marketing: We will not use your health information for marketing communications unless we
have your written consent.
Public Health and Safety: We may disclose your health information as required by law to
public health authorities for purposes of: preventing or controlling disease, injury, or disability; if
we believe you have been the victim of adult or child abuse, neglect, or domestic violence;
reporting disease or infection exposure; or to avert a serious threat to your health and safety or the
health and safety of others.
Health Oversight Activities: We may disclose your health information to health oversight
agencies for the purpose of activities authorized by law. These may include audits,
investigations, inspections, licensure and other proceedings involving governmental oversight of
the health care system.
Judicial and Administrative Proceedings: We may disclose your protected health information
in response to a court or administrative order, subpoena, discovery request, or other lawful
process.
Law Enforcement: We may disclose your health information to a law enforcement official for
purposes such as identifying of location of a suspect, fugitive, material witness, missing person,
complying with a subpoena or court order, or other law enforcement purposes.
Research, Death, Organ Donation: We may release your health information to a coroner,
medical examiner, funeral director, or organ procurement organization for certain purposes.
Workers Compensation: We may disclose your health information as necessary to comply with
worker’s compensation laws.
Public Safety: We may disclose your health information to appropriate representatives in order
to lessen or prevent a serious and imminent threat to the safety and health of a certain person or
the general public. This may include disclosing your information for military or national security
benefits.
Your Health Information Rights
Listed below are your rights concerning your health information. These may be exercised by
submitting a request to us. Each of these rights is subject to certain requirements, limitations, and
exceptions. You have the right to:
Request Restrictions: You have the right to request that we place additional restrictions on the
use and disclosure of your health information. We are not required to agree to the requested
restrictions, but if we do, we will abide by our agreement, except in the case of an emergency.
This additional request must be made to us in writing and signed by a person authorized to make
such an agreement on our behalf.
Access: You have the right to look at or get copies of your health information, with limited
exceptions. You must make a request, either orally or in writing, to the contact person listed at
the end of this notice to obtain access to your health information. We will ask that you fill out a
form specifying your request. If you request copies, we may charge you $.50 per page to locate
and copy your health information, plus any postage necessary to mail them if you want them
delivered by the postal service. If you prefer, we will prepare a summary or explanation of your
health information for a fee. Contact the person listed at the end of this notice for a full
explanation of our fee structure.
Disclosure Accounting: You have a right to receive a list of the instances that we or our
business associates disclose your health information for purposes other than treatment, payment,
health care operations, and certain other activities after April 14, 2003. After April 14, 2009, the
accounting will be provided for the past six years. If you request this accounting more than once
in a 12 month period, we may charge you a reasonable, cost-based fee for responding to your
request.
Amendment: You have the right to request amendment of your health information as long as the
information is kept by us. Your request must be in writing and state the reason for the
amendment. We may deny your request if the information was not created by us, is not part of
the health information maintained by or for us, is not part of the information for which you have a
right of access, or is already accurate and complete, in our determination. If we deny your
request, we will give you written explanation including the reason for the denial and the right to
submit a statement disagreeing with the denial.
Alternative Communication: You have the right to request that we communicate with you
about your health information by alternative means or at an alternative location. This request
must be in writing. We must accommodate your request if it is reasonable, states the alternative
means or location, and continues to permit us to bill and collect payment from you.
Request For Notice: You have a right to a paper copy of this notice. You may request a copy
from us at any time.
Changes To This Notice
We reserve the right to amend this Notice of Privacy Practices at any time, and to make the new
provisions effective for all information that it maintains, including information that was created or
received prior to the date of the amendment. Until such amendment is made, we are required by
law to comply with this notice.
Questions and Complaints
If you have any questions about this notice, would like more information about our privacy
practices, or wish to file a complaint concerning your health information, please contact:
Amy Van Arkel
Executive Director
Agape Therapy
211 West Sixth Street
Cedar Falls, Iowa, 50613
Phone 319-277-3166.
Email: avanarkel@agapetherapy.com
If you feel your rights were violated and you were not satisfied with the manner in which we
handled the complaint, you may submit a complaint to the following address. We will not
retaliate against you if you file a complaint.
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue S.W.
Room 509F HHH Building
Washington, DC 20201