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.
This Notice of Privacy Practices is effective as of [EFFECTIVE DATE].
EdgeRx LLC, together with the providers of [PROVIDER GROUP LEGAL NAME] who deliver care through the Wizlo provider network, collectively referred to as “EdgeRx,” “we,” “us,” or “our,” is required by the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations, known as HIPAA, to:
This Notice applies to the health information practices of:
EdgeRx LLC, in its role administering the technology, intake, and administrative aspects of the platform through which care is delivered.[PROVIDER GROUP LEGAL NAME] who evaluate and treat patients through the Wizlo provider network.[PHARMACY PARTNER(S)], and other vendors bound by HIPAA business associate agreements.All entities and individuals described above agree to follow this Notice with respect to PHI created or received in connection with your care.
Because EdgeRx and the affiliated provider network function as a coordinated care arrangement, we may share PHI among ourselves for treatment, payment, and health care operations as described in this Notice.
Federal law permits us to use and disclose your PHI for the following purposes without your written authorization.
We may use and disclose your PHI to provide, coordinate, or manage your health care.
For example, your provider may share your intake information and health history with a pharmacy to fill your prescription or may consult with another provider regarding your care.
We may use and disclose your PHI to obtain payment for the services we provide.
For example, we may share information necessary to process your payment with our payment processor, Gr4vy, or to verify insurance coverage or eligibility where applicable.
We may use and disclose your PHI for health care operations, including:
For example, we may review aggregated or de-identified treatment data to assess and improve the quality of care delivered through our platform.
The law may permit or require us to use and disclose your PHI without your authorization in the following circumstances.
We may disclose PHI to public health authorities for purposes such as preventing or controlling disease, injury, or disability, or reporting adverse events related to medications.
We may disclose PHI for audits, investigations, inspections, or licensure actions conducted by an authorized health oversight agency.
We may disclose PHI in response to a court order, subpoena, discovery request, or other lawful legal process, subject to applicable legal requirements.
We may disclose PHI in response to a valid warrant or subpoena, to report certain wounds or injuries as required by law, or for other authorized law enforcement purposes.
We may disclose PHI when we believe in good faith that disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or the health or safety of another person.
We may disclose PHI to a coroner or medical examiner to identify a deceased person, determine the cause of death, or as otherwise authorized by law.
We may also disclose information to funeral directors as necessary for them to carry out their duties.
We may use or disclose PHI for research in limited circumstances where the research has met regulatory requirements designed to protect your privacy, such as approval by an institutional review board or privacy board.
We may disclose PHI as necessary to comply with workers’ compensation laws or similar programs that provide benefits for work-related injuries or illnesses.
If you are a member of the armed forces, we may disclose PHI as required by applicable military authorities or for national security and intelligence activities as authorized by law.
If you are an inmate or in the custody of a correctional institution, we may disclose PHI to the institution or law enforcement official as permitted by law.
Other than the circumstances described above, we will not use or disclose your PHI without your prior written authorization.
This includes:
We will never use identifiable patient testimonials or treatment outcomes in advertising without your specific written authorization.
You may revoke a written authorization at any time by notifying us in writing, except to the extent we have already acted in reliance on that authorization.
You have the following rights with respect to your PHI, subject to certain legal limitations.
You have the right to inspect and obtain a copy of your PHI maintained in a designated record set, including your intake, consultation notes, and prescription history, with limited exceptions.
You may request access by contacting us using the information below.
We will respond within the time required by law and may charge a reasonable, cost-based fee for copies.
You have the right to request that we amend your PHI if you believe it is inaccurate or incomplete.
We may deny your request in certain circumstances, such as when the information was not created by us or is already accurate and complete.
If we deny your request, we will explain the reason in writing.
You have the right to request a list of certain disclosures of your PHI made during the six years before your request.
This accounting generally does not include disclosures made:
You have the right to request that we restrict how we use or disclose your PHI for treatment, payment, or health care operations.
We are not generally required to agree to your request.
However, we must agree to a request to restrict disclosure to a health plan for payment or health care operations if the disclosure relates to a service you paid for completely out of pocket, unless disclosure is otherwise required by law.
You have the right to request that we communicate with you about your health information through alternative means or at alternative locations.
For example, you may request that we contact you only at a specific phone number or email address.
You have the right to request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
You have the right to be notified if a breach occurs involving your unsecured PHI, as required by law.
To exercise any of these rights, contact our Privacy Officer using the information below.
We may require you to submit your request in writing and may need to verify your identity before fulfilling it.
We will respond within the timeframes required by HIPAA, which generally range from a reasonable period up to 30 days depending on the request, with a limited extension where permitted by law.
We are required by law to:
We will not use or share your PHI other than as described in this Notice unless you provide written authorization.
You may revoke that authorization at any time as described above.
We maintain administrative, technical, and physical safeguards designed to protect the confidentiality, integrity, and availability of your PHI, consistent with the HIPAA Security Rule.
These safeguards may include:
Our business associates, including our technology platform provider and pharmacy partners, are contractually required to implement appropriate safeguards and report security incidents or breaches involving PHI without unreasonable delay.
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services.
You will not be retaliated against for filing a complaint.
EdgeRx LLC30 N Gould St #4501
Sheridan, WY 82801
Privacy inquiries: team@edgerx.com
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
[STATE-SPECIFIC ADDENDA]
Some states provide additional privacy protections for certain categories of health information, including:
Counsel should insert applicable state-specific provisions after EdgeRx’s state footprint and product lines are finalized.
We reserve the right to change the terms of this Notice and make the revised Notice effective for all PHI we maintain.
If we make a material change, we will post the revised Notice on our website with a new effective date.
You may request a copy of the current Notice at any time.
If you have questions about this Notice or wish to exercise any of the rights described above, please contact our Privacy Officer:
EdgeRxLLC
Business address: 30 N Gould St #4501 Sheridan, WY 82801
Privacy inquiries: team@edgerx.com
General support: team@edgerx.com
Privacy inquiries: team@edgerx.com
General support: team@edgerx.com
Medical Director: [MEDICAL DIRECTOR NAME, MD]
