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.

Notice of Privacy Practices for Protected Health Information

Majestic Personal Care Services, LLC. is required by law to maintain the privacy of protected health information and to provide you adequate choice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. [45 CFR 165.520] We will use or disclose protected health information in a manner that is consistent with this notice.

The agency maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide you. This record includes physicians’ orders, assessments, medication lists, Care Professionals daily notes and billing information.

As required by law, the agency maintains policies and procedures about our work practices, including how we will provide, and coordinate care provided to our patients. These policies and procedures include how we create, maintain, and protect medical records; access to medical information about our patients; how we maintain the confidentiality of all information related to our patients; security of the building and electronic files; and how we initially and continually educate staff on privacy of patient information.

As our patient, information about you must be used and disclosed to other parties for purposes of treatment, payment, and health care operations. Examples of information that must be disclosed:

Treatment: Providing, coordinating, or managing health care and related services; consultation between health care providers relating to a patient; or referral of a patient for health care from one provider to another. For example, we meet on a regular basis to discuss how to coordinate care to patients and schedule visits.

Payment: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), pre-certification, medical necessity review. For example, occasionally the insurance requests a copy of the medical record be sent to them for review prior to paying the bill.

Health Care Operations: General agency administrative and business functions; quality assurance/improvement activities; performance reviews; auditing functions; developing agency guidelines; determining the competence or qualifications of Care Professionals; evaluating agency performance; conducting training programs with staff and/or new employees; licensing, survey, certification, accreditation, and credentialing activities; internal auditing; and certain fundraising and marketing activities.

The following uses and disclosures do not require your consent and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information to:

•Your insurance company, self-funded or third-party health plan, Medicare, Medicaid, or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;

•Any person or entity affiliated with or representing for purposes of administration, billing, and quality and risk management;

•Any hospital, nursing home, or other health care facility to which you may be admitted;

•Any assisted living or personal care facility of which you are a resident;

•Any physician providing your care;

•Licensing and accrediting bodies, including the information contained in the OASIS Data Set to the state agency acting as a representative of the Medicare/Medicaid program;

•Contacting you to provide appointment reminders or information about other health activities we provide;

•Other health care providers to initiate treatment.

•We are permitted to use or disclose information about you without consent or authorization in the following circumstances:

•In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment;

•Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances;

•Where we are required by law to provide treatment and we are unable to obtain consent;

•Where the use or disclosure of medical information about you is required by federal, state, or local law;

•To provide information to state or federal public health authorities, as required by law to: prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be suing; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence (if you agree or when required or authorized by law);

•Health care oversight activities such as audits, investigations, inspections, and licensure by a government health oversight agency as authorized by law to monitor the health care system, government programs, and compliance with civil rights laws;

•Certain judicial administrative proceedings if you are involved in a lawsuit or a dispute. We may disclose medical information about you in response to a court or administrative order, 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;

•Certain law enforcement purposes such as helping to identify or locate a suspect, fugitive, material witness or missing person, or to comply with a court order or subpoena and other law enforcement purposes;

•To coroners, medical examiners, and funeral directors, in certain circumstances, for example, to identify a deceased person, determine the cause of death, or to assist in carrying out their duties;

•For cadaveric organ, eye, or tissue donation purposes to communicate to organizations involved in procuring, banking, or transplanting organs and tissues (if you are an organ donor);

•For certain research purposes under very select circumstances. We may use your health information for research. Before we disclose any of your health information for such research purposes, the project will be subject to an extensive approval process. We will usually request your written authorization before granting access to your individually identifiable health information;

•To avert serious threat to health and safety: To prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict. Any disclosure, however, would only be to someone able to help prevent the threat;

•For specialized government functions, including military and veterans’ activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations;

•For Workers’ Compensation purposes: Workers’ Compensation or similar programs provide benefits for work-related injuries or illness.

•We are permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

•Use of a directory (includes names, location, condition described in general terms) of individuals served by our agency;

•To a family member, relative, friend, or other identified person, the information relevant to such person’s involvement in your care or payment for care; to notify a family member, relative, friend, or other identified person of the individual’s location, general condition, or death.

Other uses and disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time, except in limited situations.

YOUR RIGHTS – you have the right, subject to certain conditions, to:

Request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. However, we are not required to agree to any requested restriction. Restrictions to which we agree will be documented. Agreements for further restrictions may, however, be terminated under applicable circumstances (e.g., emergency treatment).

Confidential communication of protected health information. We will arrange for you to receive protected health information by reasonable alternative means or at alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.

Inspect and obtain copies of protected health information which is maintained in a designated record set, except for psychotherapy notes, information compiled in reasonable anticipation of, or four use in, a civil, criminal or administrative action or proceeding, or protected health information that is subject to the Clinical Laboratory Improvements Amendments of 1988 [42 USC 263a and 45 CFR 493 (a)(2)]. If you request a copy of your health information we will provide it for you. If we deny access to protected health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights, and an explanation to how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information.

Request to amend protected health information for as long as the protected health information is maintained in the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within sixty (60) days of receipt of the request. We may extend the time for such action by up to thirty (30) days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request. We may deny the request for amendment if the information contained in the record was not created by us, unless the originator of the information is no longer available to act on the requested amendment; is not part of the designated medical record set; and the record is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial and an explanation of how to submit the statement.

Receive an accounting of disclosures of protected health information made by our agency for up to six (6) years prior to the date on which the accounting is requested for any reason other than for treatment, payment, or health operations, and other applicable exceptions. The written accounting includes the date of each disclosure, the name/address (if known) of the entity or person who received the protected health information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure or a copy of your written authorization or a written request for disclosure. We will provide the accounting within sixty (60) days of receipt of written request. However, we may extend the time period for providing the accounting by thirty (30) days if we provide you with a written statement of the reasons for the delay and the date by which you will receive the information. We will provide the first accounting you requested during any 12-month period without charge. Subsequent account requests may be subject to a reasonable cost-based fee.

To obtain a paper copy of this notice even if you had agreed to receive this notice electronically, from us upon request.

COMPLAINTS – If you believe that your privacy rights have been violated, you may complain to the agency or to the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing, and should state the specific incident(s) in terms of subject, date, and other relevant matters. A complaint to the Secretary must describe the acts or omissions believed to be in violation of applicable requirements. [45 CFR 160.306] For further information regarding filing a complaint, contact:

Majestic Personal Care Services Privacy Officer

7601 FM 1960 East, #111

Humble, TX 77346

(832) 288-2531

EFFECTIVE DATE – This notice is effective January 1, 2019. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information that we maintain. If we change the terms of this notice (while you are receiving service), we will promptly revise and distribute an updated notice to you as soon as practicable by mail, email (if you have agreed to electronic notice), or hand delivery.

If you require further information about matters covered by this notice, please contact:

Majestic Personal Care Services Privacy Officer

Christopher Goodwin

1300 N Sam Houston Pkwy E, Suite 350

Houston, TX 77032

(832) 288-2531