Notice of
Privacy
Practices
That Witch LLC
Notice of Privacy Practices
EFFECTIVE: NOVEMBER 30, 2023
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.
DEFINED TERMS AND PURPOSE OF THIS NOTICE
The terms of this Notice of Privacy Practices (“Notice”) apply to That Witch LLC, its affiliates, and its employees (collectively, “That Witch”). This Notice describes your rights as a patient, how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. Protected health information (“PHI”) is individually identifiable health information; it includes demographic information (for example, age, address, etc.) and relates to your past, present, or future physical or mental health or condition and related health care services and payment for that care.
For more information, please visit www.hhs.gov/hipaa/for-individuals/notice-privacy-practices.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgment of receipt of this Notice. You do not have to sign the acknowledgment in order to receive care from That Witch. If you don’t sign the acknowledgment, we will continue to provide your treatment and will use and disclose your PHI only in ways that are allowed by law and do not require your authorization.
OUR RESPONSIBILITIES
That Witch is required by law to:
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Maintain the privacy and security of your PHI.
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Provide you with a copy of this Notice stating our legal duties and privacy practices with respect to your PHI.
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Abide by the terms of this Notice. We will not use or share your information other than as described here unless you tell us we can in writing.
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Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
CHANGES TO THE TERMS OF THIS NOTICE
The Notice’s effective date is at the top of the first page. We reserve the right to change the terms of this Notice, and the changes will apply to all information we have about you. If we do change this Notice, you will be notified to update your signature and date, and the updated version will be available upon request and on our website's Notice of Privacy Practices page.
OUR TYPICAL USES AND DISCLOSURES
We typically use or share your health information for the following purposes:
Treatment
We can use your health information and share it with professionals who are treating you. Example: A member of our staff obtains treatment information about you and records it in your medical record. In addition, we may contact you by phone, at your home, if we need to speak to you about a medical condition, or we may also use your medical information to remind you about an upcoming appointment.
Health care operations
We can use and disclose your information to run our organization and practice, improve your care, and contact you when necessary. Example: We may use your information to evaluate the quality of care we are providing and to develop better services for you.
Payment
We can use and disclose your health information as we bill and obtain payment for your health services. Example: We may use your information to prepare a bill to send to you or to the person responsible for your payment.
OTHER USES AND DISCLOSURES
How else can we use or share your health information? We are allowed or required to share your information without your authorization 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. The following are examples of how we may share information without your authorization:
Help with public health and safety issues
We can share health information about you for certain situations, such as:
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Preventing disease
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Helping with product recalls
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Reporting adverse reactions to medications
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Reporting suspected abuse, neglect, or domestic violence
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Preventing or reducing a serious threat to anyone’s health or safety
Perform research
We can use or share your information for health research when written permission is not required by federal or state law. This also may include preparing for research or telling you about research studies you might be interested in.
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 are complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
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For workers’ compensation claims
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For law enforcement purposes under specific conditions, such as reporting when someone is the victim of a crime
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With health oversight agencies for activities authorized by law
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For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order or a subpoena.
USES AND DISCLOSURES WITH THE OPPORTUNITY TO GIVE YOUR PREFERENCE
For certain health information, you can tell us your choices about what we use or disclose. If you have a clear preference for how we share your information in the situations described below, talk to us. The following are cases in which you have the right and choice to tell us to:
Share information with individuals involved in your health care
Unless you object, we may disclose your PHI to individuals involved in your care (such as a family member, relative, close friend, personal representative, or any other person who is responsible for your care, or any other person you identify):
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As it directly relates to that person’s involvement in your health care.
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To notify or assist in notifying said individuals of your location, general condition, or death.
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.
Share information in a disaster relief situation
We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.
USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
Following are cases in which we never share your information unless you give us written permission:
Psychotherapy notes
We do not typically maintain psychotherapy notes on any of our patients. However, if we wanted to use or disclose any psychotherapy notes we had in our possession (for instance, as part of your medical record), we would have to ask for your authorization to do so, unless the use or disclosure was to undertake certain treatment, payment, or health care operation activities as described above.
Marketing purposes
We must obtain your authorization for any use or disclosure of your PHI for marketing, except if the communication is in the form of (1) a face-to-face communication with you or (2) a promotional gift of nominal value.
Sale of your information
We must obtain your authorization prior to receiving direct or indirect remuneration in exchange for your health information.
If you change your mind after authorizing a use or disclosure of your information, you may submit a revocation of that authorization in writing. However, your revocation of the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
YOUR RIGHTS
When it comes to your health information, you have certain rights. As a patient with That Witch, you have the right to:
Review or obtain a copy of your health and claims records
You can ask to see or get an electronic or paper copy of your medical/health and claims records and other health information we have about you. We will provide a copy of your health information, usually within 30 days of your request. If you request a copy of your information, associated fees may apply for processing the copies. We will tell you in advance what this cost will be.
Request a correction of or amendment to your health and claims records
You can ask us to correct or make an amendment to your medical/claims record if you believe there is an error or discrepancy within the documentation. We may say “no” to your request, but if we say no, we’ll tell you why in writing within 60 days.
Request confidential communication
You can ask us to contact you in a specific way (for example, by 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 the information we share
You can ask us not to use or share (outside of That Witch) 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.
Obtain a copy of this Notice
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 copy promptly.
Obtain a list of those with whom we’ve shared your information
You can ask for a list of instances where we have disclosed your personal health information during the six years prior to the date the request is made. We will include all the disclosures for reasons other than treatment, payment, or other related administrative purposes and healthcare operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Choose someone to act for you
If you are unable to make health care decisions for yourself and 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 ensure the person has this authority and can act for you before we allow them to make decisions for you.
File a complaint if you feel your rights are violated
You have the right to file a complaint if you feel we have violated your rights. We cannot, and will not, retaliate against you for filing a complaint. Nor will we require you to waive the right to file a complaint with HHS as a condition of receiving treatment from That Witch. For more information, please refer to the “Complaints and Contact Information” section.
COMPLAINTS AND CONTACT INFORMATION
If you have any questions, wish to obtain copies of your health information, amend, request an accounting, or exercise any other rights identified in this Notice, or would like to file or discuss a complaint regarding our privacy practices, please contact That Witch's Privacy Officer by email at privacy@shesthatwitch.com, or in writing to:
ATTN: Privacy Officer
That Witch LLC
418 Broadway, STE R
Albany, NY 12207
Please note that all complaints must be submitted in writing to the Privacy Officer at the above address. You may also file a complaint with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). Your complaint must be filed in writing, either on paper or electronically, via the OCR Complaint Portal, by e-mail at OCRComplaint@hhs.gov, or by mail to:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
No retaliation will occur against you for filing a complaint. For more information regarding the steps to file a complaint, please visit https://www.hhs.gov/hipaa/filing-a-complaint.