Self Therapeutics Notice of Privacy Practices
This Notice of Privacy Practices describes how health information about you may be used and disclosed by Self Therapeutics, LLC (“Self Therapeutics”), and how you can get access to this information. Please review it carefully.
Self Therapeutics’ Pledge Regarding Your Health Information
Self Therapeutics understands that information about you and your health is personal. Self Therapeutics is required by law and committed to maintaining the privacy of this information. In conducting its business, Self Therapeutics creates and receives records containing your information, including the care and services you receive via the Mirror Care Platform provided and maintained by Self Therapeutics. Self Therapeutics needs these records to provide quality services and to comply with certain legal requirements. This notice applies to all of your personal health information (“PHI”), including your identifying information, records of your health and health care, and information related to payment for the provision of healthcare, generated by Self Therapeutics or received by Self Therapeutics from you or others, including via the Mirror Care Platform, whether in the form of written or electronic records or spoken words and related billing activity. Along with safeguarding your personal health information, Self Therapeutics must also make available this notice of its legal duties and privacy practices, and Self Therapeutics must follow the terms of the notice currently in effect.
This current notice takes effect on October 31, 2020, and will remain in effect until Self Therapeutics replaces it. Self Therapeutics reserves the right to change the terms of this notice at any time, as long as the changes are in compliance with applicable law. If Self Therapeutics changes the terms of this notice, the new terms will apply to all PHI it maintains, including PHI that was created or received before such changes were made. If Self Therapeutics changes this notice, it will post the new notice on its website and it will make the new notice available upon request.
This notice will tell you about the ways in which Self Therapeutics may use and disclose PHI. Self Therapeutics also describes your rights of access, amendment, control, and other rights concerning the use and disclosure of your PHI.
If you believe your privacy rights, or any right under this Notice, have been violated, you may file a complaint with Self Therapeutics, directly to our Privacy Officer: 17 W. 535 Butterfield Road, Suite 001 Oakbrook Terrace, IL 60181, . You can also file a complaint with the Secretary of the Department of Health and Human Services at or in writing to any regional HHS office. There will be no retaliation for filing a complaint.
How Self Therapeutics May Use and Disclose Health Information
The following describes ways that Self Therapeutics may use your PHI and disclose your PHI to persons and entities outside of Self Therapeutics. Not every use or disclosure has been listed within the below categories, but examples are provided for understanding.
Common Uses and Disclosures Allowed by Law
Treatment: Self Therapeutics may use your PHI to provide you services supporting your treatment, including via the Mirror Care Platform. Self Therapeutics may disclose PHI about you to others who are involved in providing, directing or overseeing your care, including, but not limited to, one or more physicians or other qualified and licensed medical professional professionals (“Providers”).
Payment: Self Therapeutics may use and disclose your PHI so that the treatment and services you receive through Self Therapeutics may be billed to and payment collected from you or a third party.
Business Operations: Self Therapeutics may use and disclose your PHI for business operations activities such as: quality assurance, administration; Self Therapeutics financial and business planning and development; and customer service (including investigation of complaints). These uses and disclosures are necessary to operate Self Therapeutics and the Mirror Care Platform, and ensure you receive quality service.
Business Associates: Some services may be provided to Self Therapeutics through contracts with business associates, such as: accountants; consultants; quality assurance reviewers; billing and transcription services. Self Therapeutics may disclose your PHI to Self Therapeutics business associates so that they can perform the job Self Therapeutics has asked them to do. Business associates are required to sign a contract that states they will appropriately safeguard your information.
Contacting You About Your Health: Self Therapeutics may use and disclose PHI to contact you, such as a reminder about an appointment, to discuss payment for services, or other treatment options at Self Therapeutics.
Individuals Involved in Your Care: Self Therapeutics may disclose to a friend or a family member or any other person that you identify who is involved in your care, PHI that directly relates to that person’s involvement in the provision of services or care, unless you tell us in advance not to do so.
Other Laws: There may be federal, state or local laws that require Self Therapeutics to disclose PHI, or give you additional privacy protections. Self Therapeutics will obey those laws.
Special Situations Which Do Not Require Your Authorization
The following disclosures of your PHI are permitted by law without any oral or written permission from you:
Public Health Activities: Self Therapeutics may disclose PHI about you for public health activities, including:
- To prevent or control disease, injury or disability;
- To report births or deaths;
- To report child abuse or neglect;
- To report reactions to medications, problems with products, or other adverse events;
- To notify people of recalls of products they may be using;
- To notify a person who may have been exposed to a disease or may be at risk for contradicting or spreading a disease or condition;
- To avert a serious threat to you or others. These disclosures would be made only to someone able to intervene;
- To notify the appropriate government authority if Self Therapeutics believes a customer has been the victim of abuse (including child abuse), neglect, or domestic violence;
- Immunization records to a school requiring such for entry, provided informal approval is given by a customer;
- To Disaster Relief agencies (such as the Red Cross) for notification as to your location and condition; and
- If you are an organ donor, Self Therapeutics may release PHI to the organizations that handle the process, as necessary to facilitate the donation.
Military and Veterans: If you are a member of the armed forces, Self Therapeutics may release PHI about you as required by military command authorities.
Worker’s Compensation: Self Therapeutics may release PHI about you for worker’s compensation and/or other similar programs relating to work-related injuries or illnesses.
Health Oversight Activities: Self Therapeutics may disclose PHI to a health oversight agency for activities authorized by law. These include audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the distribution of prescription drugs, health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, Self Therapeutics may be required to disclose your PHI in response to a court order, administrative order, subpoena, discovery request, or other lawful process by someone involved in the dispute.
Law Enforcement: Self Therapeutics may disclose PHI to law enforcement officials for reasons such as:
- In response to a court order, subpoena, warrant, or similar process;
- To identify or locate suspect, fugitive, material witness or missing person;
- About the victim of a crime if, under certain circumstances, Self Therapeutics is unable to obtain the person’s agreement;
- About criminal conduct while using Self Therapeutics services, including the Mirror Care Platform; and
- In emergency circumstances to report a crime, the location of the crime victims, or the identity, descriptions, or location of the person who committed the crime.
Health Records of Deceased Patients: Self Therapeutics may disclose PHI to a coroner or medical examiner, to identify a deceased person or determine the cause of death. Self Therapeutics may also release PHI about customers to funeral home directors as necessary to carry out their duties. We may disclose to relatives or close personal friends who were involved with the customer’s care prior to death, PHI relevant to their involvement. HIPAA privacy protections continue until 50 years after the customer’s death.
Research: Self Therapeutics may, under certain circumstances, use or disclose PHI about you that is necessary for research purposes.
National Security and Intelligence Activities: Self Therapeutics may disclose PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Required By Law: Self Therapeutics will disclose PHI about you without your permission when required to do so by federal, state, or local law.
Other Uses and Disclosures Require Your Authorization
Other uses and disclosures of PHI not covered by this notice or applicable laws will be made only with your written permission (called “authorization”). If you do provide authorization, Self Therapeutics may use and disclose your PHI in any manner consistent with that authorization. You may revoke that authorization in writing at any time. Uses and disclosures of your personal information that require your authorization include marketing functions, and most disclosures that involve sale of PHI. To authorize Self Therapeutics to disclose your PHI to a third party, or to revoke a prior authorization, send an email to email@example.com or letter to 17 W. 535 Butterfield Road, Suite 001 Oakbrook Terrace, IL 60181, requesting an authorization form or revoking your authorization.
Your Health Information Rights
You have the following rights concerning your PHI:
- Request a restriction on certain uses and disclosures of your information. Self Therapeutics may agree to your request, but is not required by law to do so, with the exception that if you pay for your treatment in full at the time of service, and request that we not disclose the information to your health plan or insurer, we will comply.
- Obtain a copy of this Notice of Privacy Practices upon request.
- Inspect and/or request a copy of PHI. You must make the request in writing, and Self Therapeutics has 30 days to comply. Self Therapeutics may charge a fee for the costs of copying, mailing or other associated labor and supplies. Self Therapeutics will provide notification of the cost involved and the request may be withdrawn or modified before any costs are incurred. Self Therapeutics will not charge a fee for inspecting your PHI. You have the right to request a copy of your PHI in electronic form if we store your PHI electronically. Self Therapeutics may deny your request to inspect and/or copy records or parts of records in certain limited circumstances. If you are denied copies of or access to, information that Self Therapeutics keeps, you may ask that the denial be reviewed. If the law gives you a right to have Self Therapeutics’ denial reviewed, Self Therapeutics will select a licensed health care professional to review the request and the denial. The person conducting the review will not be the person who denied the request, and Self Therapeutics will comply with the outcome of the review.
- Request an amendment to your health record or PHI if you feel the information is incorrect or incomplete. Self Therapeutics may deny or partially deny your request if: (a) the request is not in writing, (b) the request does not include a reason to support the request, (c) if the health record or PHI is accurate and complete as it stands; (d) Self Therapeutics did not create the information, or (e) the information you request to amend is not part of the PHI that Self Therapeutics maintains. If Self Therapeutics denies or partially denies the request for amendment, you have the right to submit a rebuttal and request the rebuttal be made a part of the service record. You also have the right to request that all documents associated with the amendment request (including rebuttal) be transmitted to any other party any time that portion of the health record or PHI is disclosed.
- Obtain an accounting of disclosures of your PHI. This will include a list of disclosures of your PHI to third parties by Self Therapeutics other than the allowed Common Uses and Disclosures Allowed by Law described above, uses described pursuant to the Special Situations Which Do Not Require Your Authorization, or uses and disclosures that you authorized. Your written request must state a time period, which may not be longer than six years. The request should indicate the desired form of the list (for example, on paper, electronically).
- Request communication of your PHI by alternative means or locations. For instance: an address or phone number other than your home.
- Revoke a previously agreed upon authorization except to the extent that action has already been taken.
- You have the right to request that Self Therapeutics communicates your PHI or health records in a certain way or at a certain location. Self Therapeutics will not ask for the reason of the request. Self Therapeutics will accommodate all reasonable requests. Requests must specify how or where you wish to be contacted.
Self Therapeutics is required by law to notify you in the event that Self Therapeutics discovers a breach of your PHI and will make every reasonable effort to inform you of a breach.
If you would like more information about your privacy rights, please send an email to the Privacy Officer at firstname.lastname@example.org.