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Butterfly Wellness is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this Notice or if you want more information about the privacy practices at Continuum Integrated Treatment Centers call (281) 969 5601.
Understanding Your Medical Record/Health Information
Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, assessment,
diagnosis, treatment plan, and treatment recommendations. These records may also disclose or reveal that you are a recipient of public
welfare benefits. This Protected Health Information (PHI), often referred to as your medical record, serves as a basis for planning your
treatment, a means to communicate between service providers involved in your care, as a legal document describing your care and
services, and verification for you and/or a third party payer that the services billed were provided to you. It can also be used as a source
of data to assure that we are continuously monitoring the quality of services and measuring outcomes. Understanding what is in your
medical record and how, when and why we use the information helps you make informed decisions when authorizing disclosure to
others. Your health information will not be disclosed without your authorization unless required or allowed by State and Federal laws,
rules or regulations.
Our Responsibilities
Butterfly Wellness must protect and secure health information that we have created or received about your past, present, or future
health condition, health care we provide to you, or payment for your health care. We are only allowed to use and disclose protected
health information in the manner described in this Notice. This Notice is posted on our website and we will provide you a paper copy of
this Notice upon your request.
How Butterfly Wellness May Use or Disclose Your Health Information
The following categories describe ways that Continuum Integrated Treatment Centers may use or disclose your health information. Any use or disclosure of your health information will be limited to the minimum information necessary to carry out the purpose of the use
or disclosure. For each category of uses and disclosures, we will explain what we mean and present some examples. Not every use or
disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the
categories.
The following categories describe ways that Continuum Integrated Treatment Centers may use or disclose your health information. Any
use or disclosure of your health information will be limited to the minimum information necessary to carry out the purpose of the use or disclosure. For each category of uses and disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the
categories.
Payment Functions – We may use or disclose health information about you to determine eligibility for plan benefits, obtain premiums,facilitate payment for the treatment and services you receive from health care providers, determine plan responsibility for benefits, and to coordinate benefits. Health information may be shared with other government programs such as Medicare or Medicaid, or private insurance to manage your medical necessity of health care services, determine whether a particular treatment is experimental or investigational, or determine whether a treatment is covered under your plan
Healthcare Operations – We may use and disclose health information about you to carry out necessary managed care/ insurancerelated activities. For example, such activities may include premium rating and other activities relating to plan coverage; conducting
quality assessment and improvement activities such as handling and investigating complaints; submitting claims for stop-loss coverage;
conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; and business
planning, management and general administration.
Treatment – Butterfly Wellness - some of our treatments require that we make a referral for an assessment or perform other activities
which include helping formulate a treatment plan, coordinating appropriate and effective care, treatment and services or setting up an
appointment with other health care providers. We may also share your health information with emergency treatment providers when
you need emergency services. We may also communicate and share information with governmental entities with whom we have Business Associate Agreements. These include hospitals, licensed facilities, licensed practitioners and governmental entities. When
these services are contracted, we may disclose your health information to our contractors so that they can provide you services and bill
you or your third-party payer for services rendered. We require the contractor to appropriately safeguard your information. We are
required to give you an opportunity to object before we are allowed to share your PHI with another HIPAA Covered Entity such as
your Primary Care Physician or another type of physical health type provider. If you wish to object to us sharing your PHI with these
types of providers, then there is a form you must sign that will be kept on file and we are required by law to honor your request.
Required by Law – Butterfly Wellness may use and disclose your health information as required by law. Some examples where we are
required by law to share limited information include but are not limited to: PHI related to your care/treatment with your next of kin,
family member, or another person that is involved in your care; with organizations such as the Red Cross during an emergency; to
report certain type of wounds or other physical injuries; and to the extent necessary to fulfill responsibilities when a consumer is
examined or committed for inpatient treatment.
Public Health- Your health information may be reported to a public health authority or other appropriate government authority
authorized by law to collect or receive information for purposes related to: preventing or controlling disease, injury or disability;
reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection
exposure.
Health Oversight Activities – We may disclose your health information to health, regulatory and/or oversight agencies during the course of audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system. For example, health information may be reviewed by investigators, auditors, accountants or lawyers who make certain that we comply with various laws; or to audit your file to make sure that no information about you was given to someone in a way that violated this Notice.
Judicial and Administrative Proceedings – We may disclose your health information in response to a subpoena or court order in the
course of any administrative or judicial proceeding, in the course of any administrative or judicial proceeding required by law (such as a
licensure action), for payment purposes (such as a collection action), or for purposes of litigation that relates to health care operations
where Continuum Integrated Treatment Centers is a party to the proceeding.
Public Safety/ Law Enforcement – We may disclose your health information to appropriate persons in order to prevent or lessen a
serious or imminent danger or threat to the health or safety of a particular person or the general public or when there is likelihood of
the commission of a felony or violent misdemeanor.
National Security - We may disclose your health information for military, prisoner, and national security.
Worker’s Compensation – We may disclose your health information as necessary to comply with worker’s compensation or similar laws.
Disclosures to Plan Sponsors - We may disclose your health information to the sponsor of your group health plan, for purposes of administering benefits under the plan. If you have a group health plan, your employer is the plan sponsor.
Applicability of More Stringent State Laws – Some of the uses and disclosures described in this notice may be limited in certain cases
by applicable State laws or rules that are more stringent than Federal laws or regulations, including disclosures related to mental health
and substance abuse, intellectual/developmental disabilities, alcohol and other drug abuse (AODA), and HIV testing.
Use and Disclosure of Health Information without your Authorization
Federal laws require or allow that we share your health information, including alcohol and drug abuse records, with others in specific
situations in which you do not have to give consent, authorize or have the opportunity to agree or object to the use and disclosure.
Prior to disclosing your health information under one of these exceptions, we will evaluate each request to ensure that only necessary
information will be disclosed. These situations include, but are not limited to the following:
• To a county Department of Social Services or law enforcement to report abuse, neglect or domestic violence; or
• To respond to a court order or subpoena; or
• To a health care provider who is providing emergency medical services; or
• To qualified service organization agencies when appropriate. (These agencies must agree to abide by the Federal law.)
When We May Not Use or Disclose Your Protected Health Information
Except as described in this Notice, Butterfly Wellness will not use or disclose your health information without written authorization from you. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in
writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the
reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your
permission.
• Your authorization is necessary for most uses and disclosures of psychotherapy notes.
• Your authorization is necessary for any disclosures of health information in which the health plan receives compensation.
• Your authorization is necessary for most uses and disclosures of alcohol and drug abuse records (exceptions are listed above).
Statement of Your Health Information Rights
Although your health information is the physical property of Butterfly Wellness, the information belongs to you. You have the right to request, in writing, certain uses and disclosures of your health information.
Right to Request Restrictions – You have the right to request a restriction on certain uses and disclosures of your health
information. We are not required to agree to the restrictions that you request. If you would like to make a request for restrictions, you
must submit your request in writing to the Privacy Officer at the address listed below. We will let you know if we can comply with the
restriction or not.
Right to Inspect and Copy - You have the right to inspect and receive an electronic or paper copy of your health information that may
be used to make decisions about your plan benefits. To inspect and copy information, you must submit your request in writing to the
Privacy Officer at the address listed below. If you request a copy of the information, we may charge you a reasonable fee to cover
expenses associated with your request. There are certain situations where we will be unable to grant your request to review records.
Right to Request Amendment - – You have a right to request that we amend your health information that you believe is incorrect or
incomplete. We are not required to change your health information and if your request is denied, we will provide you with information
about our denial and how you can appeal the denial. To request an amendment, you must make your request in writing to the Privacy
Officer at the address listed below. You must also provide a reason for your request.
Right to be Notified of a Breach - You have the right to be notified in the event that we (or one of our Business Associates) discover a
breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal
requirements
Changes to this Notice and Distribution
Butterfly Wellness reserve the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice
provisions effective for all health information that it maintains. As your health plan, we will provide a copy of our notice upon your
enrollment in the plan and will remind you at least every three years where to find our notice and how to obtain a copy of the notice if
you would like to receive one. If we have more than one Notice of Privacy Practices, we will provide you with the Notice that pertains to
you. The notice is provided and pertains to the named Medicaid beneficiary or other individual enrolled in the plan.
As a health plan that maintains a website describing our customer service and benefits, we also post to our website the most recent
Notice of Privacy Practices which will describe how your health information may be used and disclosed as well as the rights you have to
your health information. If our Notice has a material change, we will post information regarding this change to the website for you to
review. In addition, following the date of the material change, we will include a description of the change that occurred and information
on how to obtain a copy of the revised Notice in any annual mailing required by 42 CFR Part 438.
I have read, understood, and received a copy of the Center’s Notice of Privacy Practices and understand that a copy of this form will be retained in my medical chart.
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