Protected Health Information (PHI)
CardioAI is committed to protecting the privacy of your health information. We are required by law to:
We may use and disclose your health information to provide, coordinate, or manage your healthcare and related services. This includes consultation between healthcare providers regarding your care and referrals to other healthcare providers.
We may use and disclose your health information to obtain payment for services we provide. This includes billing, collections, claims management, and determinations of eligibility and coverage.
We may use and disclose your health information for our healthcare operations, including:
We may also use and disclose your health information without your authorization in the following circumstances:
| Purpose | Description |
|---|---|
| As Required By Law | When federal, state, or local law requires disclosure |
| Public Health Activities | To prevent or control disease, injury, or disability; report births, deaths, suspected abuse or neglect |
| Health Oversight Activities | To authorized health oversight agencies for audits, investigations, inspections, and licensure |
| Judicial & Administrative Proceedings | In response to court orders, subpoenas, or discovery requests |
| Law Enforcement | To law enforcement officials for specific law enforcement purposes |
| Coroners, Medical Examiners, Funeral Directors | For identification purposes, cause of death determinations, or funeral arrangements |
| Organ & Tissue Donation | To organizations involved in procurement, banking, or transplantation |
| Research | For research purposes when approved by an Institutional Review Board or Privacy Board |
| Serious Threat to Health or Safety | To prevent or lessen a serious and imminent threat to health or safety |
| Military & Veterans | If you are a member of the armed forces or veteran |
| Workers' Compensation | For workers' compensation or similar programs |
| Specialized Government Functions | For national security, intelligence activities, protective services, or correctional institutions |
You have the right to inspect and obtain a copy of your health information that may be used to make decisions about your care. This includes medical and billing records. To request access, submit a written request to our Privacy Officer. We may charge a reasonable fee for copying and mailing costs.
If you believe your health information is incorrect or incomplete, you may request an amendment. Requests must be made in writing and include a reason supporting your request. We may deny your request if the information:
You have the right to request an accounting of certain disclosures of your health information made by us during the six years prior to your request. This does not include disclosures for treatment, payment, healthcare operations, or disclosures made with your authorization.
You have the right to request restrictions on certain uses and disclosures of your health information. We are not required to agree to your request, except in the case where the disclosure is to a health plan for payment or healthcare operations purposes and the information pertains solely to a healthcare item or service for which you have paid out-of-pocket in full.
You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. For example, you may request that we contact you at home rather than work, or via mail rather than phone.
You have the right to obtain a paper copy of this Notice at any time, even if you have agreed to receive it electronically. You may request a copy from our Privacy Officer or download it from our website.
You have the right to be notified in the event that we (or a Business Associate) discover a breach of your unsecured health information.
Other than as described in this Notice, we will not use or disclose your health information without your written authorization. The following uses and disclosures require your authorization:
You may revoke any authorization you provide at any time by submitting a written revocation to our Privacy Officer. The revocation will not affect any uses or disclosures already made in reliance on your authorization.
We are required by law to:
We implement appropriate physical, technical, and administrative safeguards to protect your health information, including:
We reserve the right to change this Notice and to make the revised or changed Notice effective for health information we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice on our website and in our facility. The Notice will contain the effective date on the first page.
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. You will not be retaliated against for filing a complaint.
With CardioAI:
With the Federal Government:
Privacy Officer: HIPAA Compliance Officer
Organization: CardioAI
Address: [Insert Your Address]
Phone: (614) 356-7890
Email: privacy@cardioailive.com
Website: www.cardioailive.com
Office Hours: Monday - Friday, 9:00 AM - 5:00 PM EST
I acknowledge that I have received a copy of CardioAI's Notice of Privacy Practices.
Patient/Legal Representative Name (Print):
Signature:
Date:
If signed by legal representative, please indicate relationship to patient: