Mobius Mobility LLC

Notice of Privacy Practices

Notice of Privacy Practices Effective Date: June 27, 2019 Page 1 Mobius Mobility LLC Notice of Privacy Practices

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.

Mobius Mobility LLC is required by law to protect the privacy of your health information, to provide you with notice of its legal duties and privacy practices with respect to your health information, to notify you if you are affected by a breach of unsecured health information, and to follow the terms of our notice that is currently in effect. If you have questions about any part of this notice, or if you want more information about the privacy practices at Mobius Mobility LLC, please contact:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
Info@mobiusmobility.com
(603) 206-0550

Effective Date of this notice: June 27, 2019

Mobius Mobility collects health information from you and stores it on printed paper and on electronic computer systems. The collection of your health information is considered your medical record. Mobius Mobility LLC cares about and protects the privacy of your health information.

I. How Mobius Mobility LLC may use or disclose your health information.

The law allows Mobius Mobility LLC to use or disclose your health information for the following purposes:

1. Treatment. We may use and share your health information with other professionals who are working with Mobius Mobility LLC to provide you with treatment. For example, we may use or disclose your health information with doctors, therapists, or assistive technology professionals to ensure that you are provided with the mobility option that is most appropriate for you.

2. Payment. We may use and share your health information to bill and get payment from health plans or other entities. For example, we may disclose your health information to your health insurance plan to allow your health insurance plan to pay for your mobility device.

3. Health Care Operations. We may use and share your health information to run our business, improve your care, and contact you when necessary. For example, we may use and disclose your health information for quality assessments, audits, business planning, business administration, and to ensure compliance with federal or state law.

4. Information provided to you. We may discuss your health information with you to better understand your mobility needs.

5. Appointment reminders. We may use and disclose health information to contact you to remind you that you have an appointment with us.

6. Individuals involved in your care or payment for your care. When appropriate, we may share health information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

7. Research. Under certain circumstances, we may use and disclose health information for research purposes. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose health information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any health information.

SPECIAL SITUATIONS

1. As required by law. We will disclose health information when required to do so by international, federal, state, or local law.

2. To avert a serious threat to health or safety. We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of others. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

3. Business Associates. We may disclose health information to our Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may collaborate with a security company to ensure that your health information is appropriately safeguarded. All of our Business Associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

4. Organ and tissue donation. If you are an organ donor, we may use or release health information to organizations that handle organ procurement or other entities engaged in procurement, banking, or transportation of organs, eyes, or tissues to facilitate donation and transplantation.

5. Military and veterans. If you are a member of the armed forces, we may release health information as required by military command authorities. We also may release health information to the appropriate foreign military authority if you are a member of a foreign military.

6. Workers’ compensation. We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

7. Public health risks. We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury, or disability; to report births and deaths; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to prevent a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition from spreading it to the public; and to report to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make these disclosure if you agree or when we are required or authorized by law.

8. Health oversight activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

9. Data breach notification purposes. We may use or disclose your health information to provide legally required notices of unauthorized access to or disclosure of your health information.

10. Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

11. Law enforcement. We may release health information if asked by a law enforcement official if the information is (1) in response to a court order, subpoena, warrant, summons, or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

12. Coroners, medical examiners, and funeral directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release health information to funeral directors as necessary for their duties.

13. National security and intelligence activities. We may release health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

14. Protective services for the president and others. We may disclose health information to authorized federal officials so they may provide protection to the president, other authorized persons, or foreign heads of state, or conduct special investigations.

15. Inmates or individuals in custody. If you are an inmate of a correctional institute or under the custody of a law enforcement official, we may release health information to the correctional institute or law enforcement official. This release would be, if necessary (1) for the institute to provide you with health care, (2) to protect your health and safety or the health and safety of others, or (3) to protect the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT

1. Individuals involved in your care or payment for your care. Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

2. Disaster relief. We may disclose your health information to disaster relief organizations that seek your health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES.

I Unless otherwise required by this Notice of Privacy Practices, the following uses and disclosures of your health information will be made only with your written authorization:

1. Uses and disclosures of psychotherapy notes;

2. Uses and disclosures for marketing purposes; and

3. Disclosures that constitute a sale of your health information.

II. When Mobius Mobility LLC may not use or disclose your health information

Mobius Mobility will not use or disclose your health information without written authorization, except as provided in this Notice of Privacy Practices. If you authorize Mobius Mobility LLC to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time by submitting a written revocation to our HIPAA Compliance Officer:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

Upon receipt of such written revocation, we will no longer disclose your health information under the authorization. However, use and disclosure that was made in reliance of your authorization before you revoked it will not be affected by the revocation.

III. Your health information rights

You have the following rights regarding health information that we have about you:

1. Right to inspect and copy. You have a right to inspect and copy health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this health information, you must make your request, in writing, to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

We have up to 30 days to make your health information available to you. We may deny your request in certain limited circumstances, including situations where we are legally obligated to keep the health information confidential. If we do deny your request, you have the right to have the denial reviewed by a licensed health care professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

2. Right to an electronic copy of your electronic medical records. If your health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your health information in the form or format that you request, if it is readily producible in such form or format. If your health information is not readily producible in the form or format that you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form.

3. Right to get notice of a breach. You have the right to be notified of a breach of any of your unsecured health information.

4. Right to amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Mobius Mobility LLC. To request an amendment, you must make your request, in writing, to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

We typically have up to 60 days to respond to your request for amendment. We may deny your request in certain limited circumstances, including situations where we are not legally permitted to amend the health information.

5. Right to an accounting of disclosures. You have the right to request a list of certain disclosures of health information that we made, excluding disclosures made for certain purposes, including treatment, payment, health care operations, national security, or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

6. Right to request restrictions. You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment of your care, such as a family member or friend. For example, you could ask that we do not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

7. Out-of-pocket payments. If you paid “out of pocket” (or in other words, you have requested that we do not bill your health plan) in full for a specific item or service, you have the right to ask that your health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

8. Right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

9. Right to a paper copy of this notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain an electronic copy of this notice at our website (www.mobiusmobility.com). To obtain a paper copy of this notice, you must make your request, in writing, to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

IV. Changes to this Notice of Privacy Practices

Mobius Mobility LLC reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, Mobius Mobility LLC is required by law to comply with this notice. Mobius Mobility will provide you with an updated Notice of Privacy Practices upon request. Requests must be made in writing to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

V. Complaints

Complaints about this Notice of Privacy Practices or how Mobius Mobility LLC handles your health information should be directed to:

HIPAA Compliance Officer
Mobius Mobility, LLC
540 N. Commercial Street, Suite 310
Manchester, NH 03101
info@mobiusmobility.com

All complaints must be made in writing. You will not be retaliated against for filing a complaint. If you are not satisfied with the manner in which Mobius Mobility LLC handles a complaint, you may submit a formal complaint to:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F HHH Building
Washington, DC 20201

VI. Acknowledgement

I hereby acknowledge that I have read and understand the content of this Notice of Privacy Practices.

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Printed Name

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