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.
When it comes to your health information, you have certain rights. This section explains your
rights and some of our responsibilities to help you.
Get a copy of your
health and claims records
• You can ask to see or get a copy of your health and claims records and other
health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually
within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health
and claims records
• You can ask us to correct your health and claims records if you think they are
incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within
• You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you
would be in danger if we do not.
Ask us to limit what
we use or share
• You can ask us not to use or share certain health information for treatment,
payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it
would affect your care.
Get a list of those with
whom we’ve shared
• You can ask for a list (accounting) of the times we’ve shared your health
information for six years prior to the date you ask, who we shared it with,
• We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures (such as
any you asked us to make). We’ll provide one accounting a year for free but
will charge a reasonable, cost-based fee if you ask for another one within
Get a copy of this
• You can ask for a paper copy of this notice at any time, even if you have
agreed to receive the notice electronically. We will provide you with a paper
to act for you
• If you have given someone medical power of attorney or if someone is your
legal guardian, that person can exercise your rights and make choices about
your health information.
• We will make sure the person has this authority and can act for you before
we take any action.
File a complaint if
you feel your rights
• You can complain if you feel we have violated your rights by contacting us
using the information on page 1.
• 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
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you
have a clear preference for how we share your information in the situations described below, talk to us. Tell
us what you want us to do, and we will follow your instructions.
In these cases, you have
both the right and choice
to tell us to:
• Share information with your family, close friends, or others involved in
payment for your care
• Share information in a disaster relief situation
• Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are
unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never
share your information
unless you give us
• Marketing purposes
• Sale of your information
How do we typically use or share your health information? We typically use or share your health
information in the following ways.
the health care
• We can use your health information
and share it with professionals who are
Example: A doctor sends us information
about your diagnosis and treatment plan
so we can arrange additional services.
• We can use and disclose your
information to run our organization
and contact you when necessary.
• We are not allowed to use genetic
information to decide whether
we will give you coverage and the
price of that coverage. This does
not apply to long term care plans.
Example: We use health information
about you to develop better services
Pay for your
• We can use and disclose your health
information as we pay for your health
Example: We share information about
you with your dental plan to coordinate
payment for your dental work.
• We may disclose your health information
to your health plan sponsor for plan
Example: Your company contracts with us
to provide a health plan, and we provide
your company with certain statistics to
explain the premiums we charge.
How else can we use or share your health information? 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.
Help with public health
and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it,
including with the Department of Health and Human Services if it wants to
see that we’re complying with federal privacy law.
Respond to organ and tissue
donation requests and work
with a medical examiner or
• We can share health information about you with organ procurement
• We can share health information with a coroner, medical examiner, or
funeral director when an individual dies.
enforcement, and other
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security,
and presidential protective services
Respond to lawsuits and
• We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The
new notice will be available upon request, on our web site, and we will mail a copy to you.This Notice of Privacy Practices applies to Freedom Medical Services, Inc. (dba FreedoMed) with an Effective Date of October 1, 2017.
edoMed) with an Effective Date of October 1, 2017.