IndividuALLytics

Better Care, Better Health for Patients, Doctors and Health Systems

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Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES – IndividuALLytics Inc and IAQplus Connected Care For more information, contact:
IndividuALLytics, Inc
IAQplus Connected Care (the “Provider”)

Chief Privacy Officer
330 East Liberty Street
Ann Arbor, MI 48104
(888) 905-4540

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

  • Get a copy of your electronic medical record
  • Correct your electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your ChoicesYou have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide mental health care
  • Market our services and sell your information

Our Uses and Disclosures
We may use and share your information as we:

  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

Your Rights

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 an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record 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 information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is 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 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone or email) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

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.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • 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, and why.
  • 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 12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Upon request, we will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, thatperson 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 are violated

  • You can complain if you feel we have violated your rights by contacting us.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for CivilRights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
  • We will not retaliate against you for filing a complaint.

Your Choices

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.
You have the right to tell us to:

• Share information with your family, close friends, or others involved in your care (or not to)

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 written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In addition, mental health records may be withheld from you if your provider determines that disclosure would be detrimental to you.

Our Uses and Disclosures

How do we typically use or share your health information?We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your health information to run our practice, improve your care, and to contact you when necessary. Example: We use health information about you to manage your treatment and services.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
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

Do research

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

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:
• 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 legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

  • 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 your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it upon request.
  • We never sell identifiable personal information.
  • We will not use or share your information other than as described here unless you tell us we canin 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, and your updated instructions will apply to any future requests for information that we receive.
  • Federal and state laws may place additional limitations on the disclosure of your health information related to drug or alcohol abuse treatment programs, sexually transmitted diseases, genetic information, or mental health treatment programs. When required by law, we will obtain your authorization before releasing this type of information.

    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.

    Patient Bill of Rights
    Many states have adopted a patient bill of rights applicable to patients of physicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to the Service is provided to you here on behalf of OCN. Please note that it includes patient responsibilities as well.

    A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

    A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.A patient has the right to know who is providing medical services and who is responsible for his or her care.

    A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.A patient has the right to know what rules and regulations apply to his or her conduct.

    A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.

    A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.
    A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.

A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.

A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.

A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.

A patient is responsible for reporting unexpected changes in his or her condition to the Provider.

A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.

A patient is responsible for following the treatment plan recommended by the Provider.
A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.

State Specific Notifications (See Below For State Specific Mental Health Notifications)

FOR CALIFORNIA RESIDENTS
You or your legal representative retains the option to withhold or withdraw consent to receive health care services via the Service at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which you or your legal representative would otherwise be entitled.

All existing confidentiality protections apply.

All existing laws regarding patient access to medical information and copies of medical records apply.

Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

All provisions herein, including your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit.

NOTICE
Medical doctors are licensed and regulated by the Medical Board of California (800) 632-2322
www.mbc.ca.gov

FOR FLORIDA RESIDENTS
Each provider’s hours are variable. To access a provider’s in-office schedule, go to that provider’s login page where the provider’s in-office hours are posted.

FOR GEORGIA RESIDENTS

Patient Right to Know

The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The patient should be able to provide the physician or practice name, the address, and the specific nature of the complaint.

FOR INDIANA RESIDENTS
Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.

I expressly consent to providers forwarding my patient identifiable information to the third party payor responsible for the Service or its designee. I agree that I will hold harmless said payor(s), American Well Corporation and Provider for any loss of information due to a technical failure.

Notice Concerning Complaints

You may either file a complaint online or download the appropriate complaint form found at
http://www.indianaconsumer.com/filecomplaint.asp. If downloading, you must complete, sign, print, and mail it, along with copies of all relevant supporting documentation to:

Consumer Protection Division
Office of the Indiana Attorney General 302 W. Washington St., 5th Floor Indianapolis, IN 46204

You can also request a complaint form by calling 800-382-5516 or 317-232-6330.

FOR KANSAS RESIDENTS
Notice to Patients: Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts
April 5, 2007

NOTICE TO PATIENTS

It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas.

Questions and concerns regarding this professional practice may be directed to:

KANSAS STATE BOARD OF HEALING ARTS

235 S. Topeka Boulevard
Topeka, Kansas 66603
PHONE: (785) 296-7413
TOLL FREE: 1(888) 886-7205
FAX: (785) 296-0852
WEBSITE: www.ksbha.org

FOR LOUISIANA RESIDENTS
The relationship between you and the Provider is not intended to replace the relationship between you and other providers. The relationship between you and the Provider is supplemental. Your primary care physician is responsible for your overall health care management.

FOR MARYLAND RESIDENTS
Our procedure to verify the identification of the individual transmitting the communication:

We verify your identification through the assignment and use of a unique username and password combination. When you sign into the Service, your username and password identify you.

Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to you are personal to you and you must not share them with any other individual.

When you choose a provider, you will set up an appointment time. Provider is hereby providing you with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with you and respond to your questions in real time.

FOR OKLAHOMA RESIDENTS
You always retain the option to withhold or withdraw consent from obtaining health care services via the Service. If you decide that you no longer wish to obtain health care services via the Service, it will not affect your right to future care or treatment, nor will you risk the loss or withdrawal of any program benefits to which you would otherwise be entitled.

Patient access to all medical information transmitted during a telemedicine interaction is guaranteed by the provider and copies of this information are available at stated costs, which shall not exceed the direct cost of providing the copies.

All existing confidentiality protections apply.

Dissemination of any of any of your identifiable images or information from the telemedicine interaction to researches or other entities shall not occur without your consent.

FOR SOUTH DAKOTA RESIDENTS
SHOULD ANY PATIENT WISH TO DISCUSS FEES OR CHARGES, YOU ARE ENCOURAGED TO ASK ABOUT THEM.

FOR TEXAS RESIDENTS
An additional in-person medical evaluation may be necessary to meet your needs if the provider is unable to gather all the clinical information via the Service to safely treat you.

Unless your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service.

The response time for emails, electronic messages and other communications can be found on your provider’s login page.

NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC- 263 Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353

For more information please visit our website at www.tmb.state.tx.us

AVISO SOBRE LAS QUEJAS
Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos en la Junta de Examinadores Médicos del Estado de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC- 263 Austin, Texas 78768-2018

Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353

Para obtener más información, viwebsite nuestro sitio web en www.tmb.state.tx.us

FOR VIRGINIA RESIDENTS
We are happy to maintain your records while you are an active patient or to transfer your records to another practitioner or health care provider should you wish to seek care elsewhere. We consider patients inactive if they either ask to have their records transferred or they have not been seen in any of our offices for six years. Our policy is to destroy inactive medical records in accordance with the Virginia Department of Health Professions regulations.

These regulations (18VAC85-20-26) state that practitioners must maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:

1. Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;

2. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or

3. Records that are required by contractual obligation or federal law to be maintained for a longer period of time.

Practitioners must post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records can only be destroyed in a manner that protects patient confidentiality, such as by incineration or shredding. For more information from the Virginia Department of Health Professions, go to www.dhp.virginia.gov/Medicine.

FOR WISCONSIN RESIDENTS
Patients have the right to receive information regarding fees charged for a health care service, diagnostic test, or procedure identified by the patient and provided by the Provider.

State Specific Mental Health Notifications

FOR DISTRICT OF COLUMBIA RESIDENTS
Your written authorization (which you provide with respect to disclosures required for treatment, payment and health care operations by agreeing to American Well Corporation’s Terms of Use) is required for disclosure of mental health information. Subject to a limitation imposed by the mental health professional primarily responsible for your diagnosis and treatment, which may be imposed only if necessary to protect you or another from a substantial risk of imminent and serious physical injury, you are entitled to receive a copy of your mental health record within 30 days of receipt of the request.

FOR HAWAII RESIDENTS
Mental health, mental illness, drug addiction and alcoholism records that directly or indirectly identify you shall be kept confidential and may only be disclosed under limited circumstances, including with consent from you or your legal guardian. Disclosures may only be made to third party payors if you are informed and afforded the opportunity to pay directly. If you are a self-pay patient then no disclosure will be made to third party payors. If your access to the Service is provided through an employer or payor arrangement, and a third party pays some or all of the cost of your mental health services, then accessing the Service for this purpose constitutes your agreement to our disclosure of so much information as is required to secure such payment.

FOR MICHIGAN RESIDENTS
As long as you have not been found incompetent and do not have a guardian, you have the right to your mental health records. Provider will provide the records to you within 30 days of receipt of your request, or if you request the records during a course of treatment, by the conclusion or other termination of your course of treatment, if earlier.

FOR MINNESOTA RESIDENTS
Upon written request of your spouse, parent, child or sibling, if you are evaluated for or diagnosed with mental illness, provider must ask you whether you wish to authorize a specific individual to receive information regarding treatment. If authorized, provider shall communicate about your treatment with such individual. In addition, a Provider providing mental health treatment may disclose limited information to a family member/other person if: the request is in writing; the person lives with, provides care for, or is directly involved in your treatment and that involvement is verified by and documented in the medical record; before disclosure, you are informed in writing of the request, the person making the request, and the reason for the request; your agreement, objection or inability to consent or object is documented in the patient’s record; and disclosure is necessary for the patient’s treatment.

FOR SOUTH DAKOTA RESIDENTS
You have the right of access to your mental health records upon request.

FOR CONNECTICUT RESIDENTS
You can verify a practitioner’s license number directly with the State of Connecticut through their primary source database which contains up-to-date information. Please visit the Connecticut eLicense web portal at https://www.elicense.ct.gov/Lookup/LicenseLookup.aspx to search by the practitioner’s first and last name.