Notice of Privacy Practices

This notice describes how medical information about you may be used
and disclosed and how you may receive access to this information.

OUR COMMITMENT TO YOU

Synergy Wound Technology, Inc dba InteliWound is committed to maintaining the privacy of your health information. During your InteliWound wound assessment, information about your health history and your current health status may be collected. This Notice explains how that information, called “Protected Health Information” may be used and disclosed to others. The terms of this Notice apply to health information produced or obtained by Synergy Wound Technology, Inc.

1. OUR LEGAL DUTIES

The HIPAA Privacy Law requires us to provide this Notice to you regarding our privacy practices, our legal duties to protect your private information and your rights concerning health information about you. We are required to follow the privacy practices described in this Notice whenever we use or disclose your protected health information (PHI). Other companies or persons that perform services on our behalf, called Business Associates, must also protect the privacy of your information. Business Associates are not allowed to release your information to anyone else unless specifically permitted by law. There may be other state and federal laws, which provide additional protections related to communicable disease, mental health, substance or alcohol abuse, or other health conditions.

2. YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED

The HIPAA Privacy Law permits Synergy Wound Technology, Inc to make uses and disclosures of your health information for purposes of payment and health care operations.

– Wound Assessment:

The HIPAA Privacy Law permits Synergy Wound Technology, Inc to make uses and disclosures of your health information for purposes of payment and health care operations.

– Payment:

We may use and disclose health information about you to obtain payment for the care and services that we have provided to you. For example, we may need to provide your health plan provider with information about you and the InteliWound wound assessment provided to you at Synergy Wound Technology, Inc so that your health insurer will pay us, or reimburse you, for the treatment. We may also contact your health insurance to obtain prior approval about a potential treatment.

– Health Care Operations:

We may use and share health information about you for Synergy Wound Technology’s health care operations, which include planning, management, quality assessment, and improvement activities for the wound assessments that we deliver.

– Research:

Federal law permits Synergy Wound Technology, Inc to use or disclose health information about you for research purposes, if the research is reviewed and approved by an Institutional Review Board to protect the privacy of your health information before the study begins. We may disclose your information if we have your written authorization to do so. In some instances, researchers may be allowed to use information about you in a restricted way to determine whether the potential study participants are appropriate. We will make a “good faith effort” to acquire your permission or rejection to participate in any research study prior to releasing any protected information about you.

– As Required by Law:

We must disclose health information about you if federal, state, or local law requires us.

– Specialized Government Functions:

If you are a member of the military or a veteran, we will disclose health information about you as required by command authorities; or if you give us your written permission. We may also disclose your health information for other specialized government functions such as national security or intelligence activities.

– Lawsuits and Disputes:

If you are involved in a lawsuit, dispute, or other judicial proceeding, we may disclose health information about you in response to a court order or subpoena, other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

– Law Enforcement:

We may disclose your health information to a law enforcement official if required or allowed by law, such as for gunshot wounds and some burns. We may also disclose information about you to law enforcement that is not a part of your health record for the following reasons:

To identify or locate a suspect, fugitive, material witness, victim of a crime, or missing person.
About a death we believe may be the result of criminal conduct.
About criminal conduct at our location.
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

– Correctional Facilities:

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official only as required by law or with your written permission. We may release your health information for your health and safety, for the health and safety of others, or for the safety and security of the correctional institution.

– Coroners, Medical Examiners, and Funeral Directors:

We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release your PHI to a funeral director, as necessary, to carry out his/her duties.

– Required by HIPAA Law:

The Secretary of the Department of Health and Human Services (HHS) may investigate privacy violations. If your health information is requested as part of an investigation, we must share your information with HHS.

3. SITUATIONS IN WHICH YOUR HEALTH INFORMATION MAY BE DISCLOSED WITH YOUR WRITTEN CONSENT

For any purpose other than the ones described above, we may only use or share your health information when you give us your written authorization to do so. For example, you will need to sign an authorization form before we can send your health information to your life insurance company. You may revoke an authorization at any time.

– Marketing:

We must also obtain your written authorization before using your health information to send you any marketing materials. The only exceptions to this requirement are that:

We can provide you with marketing materials in a face-to-face encounter or a promotional gift of very small value, if we so choose.
We may communicate with you about products or services relating to your treatment, to coordinate or manage your care.

YOUR RIGHTS REGARDING HEALTH INFORMATION WE MAINTAIN ABOUT YOU

– Right to Inspect and Copy:

You have the right to inspect and receive a copy of your PHI. A request to inspect your records may be made to your nurse, doctor or to Synergy Wound Technology, Inc. For copies of your PHI, requests must go Synergy Wound Technology, Inc. For PHI in a designated record set that is maintained in an electronic format, you can request an electronic copy of such information. There may be a charge for copies of your PHI.

– Right to Request Amendment:

If you believe that any health information we have about you is incorrect or incomplete, you have the right to ask us to change the information, for as long as Synergy Wound Technology maintains the information. To request an amendment to your health information, your request must be in writing, signed, and submitted to Synergy Wound Technology, Inc. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be maintained with your records. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

– Right to Request Restrictions on Use and Disclosure:

You have the right to request a restriction or limitation on certain uses and disclosures of your health information.
To request restrictions, you must make your request in writing to Synergy Wound Technology, Inc. In your request, you must tell us:

What information you wish to limit.
Whether you wish to limit our use, disclosure, or both.
To whom you want the limits to apply – for example, if you want to prohibit disclosures for insurance payment, health care operations, for disaster relief purposes, to persons involved in your care, or to your spouse.

You or your personal representative must sign it.
We are not required to agree to your request, but we will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction.

– Right to Receive a Copy of this Notice:

You have the right to a paper copy of this Notice of Privacy Practices even if you have agreed to receive the Notice electronically. You may ask us to give you a copy of this Notice at any time.

– Right to Cancel Authorization to Use or Disclose:

Other uses and disclosures of your health information not covered by this Notice or the laws that govern us will be made only with your written authorization. You have the right to revoke your authorization in writing at any time, and we will discontinue future uses and disclosures of your health information for the reasons covered by your authorization. We are unable to take back any disclosures that were already made with your authorization, and we are required to retain the records of the care that we provided to you.

4. PHOTOGRAPHY

In order to complete the InteliWound wound assessment provided to you by Synergy Wound Technology, Inc, the patient understands that photographs of the affected area may be a necessary step in the wound assessment process.
All photographs will be managed securely according to HIPAA guidelines and will not be released without consent or based on the guidelines outlined in sections I-V.

For further information:

If you have questions, or would like additional information, you may contact info@inteliwound.com at Synergy Wound Technology, Inc.

To File a Complaint:

You may submit any complaints with respect to violations of your privacy rights to Synergy Wound Technology, Inc. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services if you feel that your rights have been violated. There will be no retaliation from Synergy Wound Technology, Inc for making a complaint.

Contact Information:

Unless otherwise specified, to exercise any of the rights described in this Notice, for more information, or to file a complaint, please contact info@inteliwound.com.

Effective Date:

This Notice is effective as of March 11, 2018.

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