HIPAA Notice of Privacy Practices

Kultivate Women's Health LLC: HIPAA Privacy Policy & Consent for Care

Privacy Policy

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.

1. Our Commitment to Your Privacy
At Kultivate Women's Health (KWH), we respect your privacy and are committed to protecting your personal health information. Federal and state laws require us to protect your health information, explain how we use and share it, and inform you of your rights. This notice applies to the protected health information (PHI) we maintain about you, including information in your medical records, electronic communications, and other practice records.

2. How We Use and Share Your Health Information
We may use or share your health information without your written authorization for treatment, payment, healthcare operations, and other purposes permitted or required by law.

Treatment

  • We may use and share your information with healthcare professionals involved in your care.

  • For example, we may share information with your primary care provider, specialist, laboratory, pharmacy, or another healthcare professional to coordinate your treatment.

Payment

  • We may use and share health information to process payments and support related activities.

  • Although KWH is a private-pay practice, insurance may be involved in certain services, such as laboratory testing or prescription medications.

  • For example, we may provide necessary information to a pharmacy or health plan to support a medication authorization.

Healthcare Operations

  • We may use information to operate and improve our practice. This may include quality improvement, staff training, patient communications, and administrative activities.

  • For example, we may review patient records internally to evaluate and improve the care we provide.

Appointment Reminders and Patient Communications

  • We may contact you by telephone, email, text message, or through our patient portal regarding appointments, test results, treatment, prescriptions, or other healthcare-related matters.

  • We use approved communication systems and appropriate safeguards to protect your information.

  • You may request reasonable alternative methods of communication.

3. Health Information Exchange – CliniSync

Kultivate Women's Health participates in CliniSync, Ohio's Health Information Exchange (HIE), operated by the Ohio Health Information Partnership. CliniSync allows authorized participating healthcare providers to securely access and exchange health information to coordinate patient care. Information available through CliniSync may include:

  • Medical history and diagnoses

  • Medications and allergies

  • Laboratory and imaging results

  • Hospital visits and treatment records

  • Other information relevant to your healthcare

Sharing information through CliniSync may help providers coordinate treatment, reduce duplicate testing, and access important medical information during emergencies.

Your Right to Opt Out

Participation in CliniSync is generally automatic when you receive care from a participating healthcare provider. However, you have the right to opt out. If you choose to opt out, your medical information will no longer be accessible to participating providers through CliniSync in accordance with its consent policies. This may limit another provider's access to important information, including during an emergency. Opting out of CliniSync does not prevent other uses or disclosures of your health information that are permitted or required by law.

How to Opt Out
You may request an opt-out through Kultivate Women's Health by contacting our office and requesting the CliniSync Request to Change Consent form. You may also submit the completed, signed, and notarized form directly to CliniSync:

Ohio Health Information Partnership
Attn: Consent Status
3455 Mill Run Drive, Suite 315
Hilliard, OH 43026
Phone: 614-664-2600
Email: information@clinisync.org

Additional information and the Request to Change Consent form are available at: https://clinisync.org/patient-choice/

Your decision to opt out will not affect your ability to receive medical care at KWH.

4. Other Uses and Disclosures Permitted by Law

We may use or disclose your health information without written authorization in certain circumstances, subject to applicable legal requirements.

These may include:

  • Public Health: Reporting communicable diseases, adverse medication reactions, product recalls, or other information to authorized public health agencies.

  • Health Oversight: Cooperating with authorized audits, investigations, inspections, and licensing activities.

  • Required Reporting: Reporting suspected abuse, neglect, or other matters when required or permitted by law.

  • Health and Safety: Sharing information when necessary to prevent or reduce a serious threat to health or safety.

  • Legal Proceedings: Responding to valid court orders, subpoenas, or other legal processes when disclosure is authorized or required.

  • Law Enforcement: Providing information to law enforcement officials when permitted or required by law.

  • Workers' Compensation: Disclosing information as authorized by applicable workers' compensation laws.

  • Organ Donation: Sharing relevant information with authorized organ or tissue procurement organizations.

  • Medical Examiners and Funeral Directors: Providing information when permitted by law.

  • Government Functions: Making certain disclosures for military, national security, or other authorized government activities

  • Research: KWH does not routinely use identifiable patient records for research. Any research-related use or disclosure must have appropriate authorization or meet an applicable legal exception.

Each disclosure is evaluated according to applicable privacy and confidentiality requirements.

5. Family Members and Others Involved in Your Care

You may tell us whether you want information shared with family members, friends, or others involved in your care or payment for your care. When appropriate, we may share relevant information with these individuals if you agree or have an opportunity to object and do not object. If you are unable to communicate your preferences, we may use professional judgment to determine whether a limited disclosure is in your best interest, as permitted by law. We may also share information for disaster relief purposes when permitted. We will not assume that someone has unrestricted access to your medical information simply because they are a family member.

6. Uses That Require Your Written Authorization

Certain uses and disclosures of your protected health information require your written authorization unless an exception applies.

These may include:

  • Marketing activities that require authorization under HIPAA

  • The sale of protected health information

  • Most uses and disclosures of psychotherapy notes, if applicable

  • Other uses or disclosures not otherwise permitted by law or described in this notice

We may provide information about KWH services, patient education, or treatment options when permitted by HIPAA without separate authorization. We will obtain written authorization for marketing communications when required by law. If we use PHI for fundraising communications, you will have the right to opt out of receiving them. Additional protections apply to fundraising involving records protected under 42 CFR Part 2. You may revoke an authorization in writing at any time. Revocation will not affect actions already taken in reliance on the authorization.

7. Special Protections for Substance Use Disorder Records

Certain substance use disorder treatment records are protected by additional federal confidentiality requirements under 42 CFR Part 2. When KWH receives or maintains records subject to these requirements, we follow the applicable rules governing their use and disclosure, including any required patient consent. Where permitted by Part 2 and with an appropriate consent, protected records may be used or disclosed for treatment, payment, and healthcare operations. Other disclosures remain subject to applicable legal restrictions. Records protected under Part 2, and testimony describing their contents, generally cannot be used or disclosed in civil, criminal, administrative, or legislative investigations or proceedings against you without your specific written consent or a qualifying court order and accompanying legal process. These protections apply in addition to applicable HIPAA requirements.

8. Your Rights Regarding Your Health Information

You have important rights concerning the health information we maintain.

Access Your Medical Records

  • You may request to review or receive an electronic or paper copy of your medical records and other information maintained in our designated record set.

  • We will generally respond within 30 calendar days, subject to applicable exceptions and permitted extensions.

  • We may charge a reasonable, cost-based fee for certain copying or delivery expenses permitted by law. We do not charge for searching for or retrieving your records.

Request an Amendment

  • If you believe information in your medical record is incorrect or incomplete, you may request an amendment.

  • We will generally respond within 60 days, subject to applicable exceptions and permitted extensions.

  • If we deny your request, we will explain the reason in writing and inform you of your applicable rights.

Request Restrictions

  • You may ask us to limit certain uses or disclosures of your health information.

  • We are not generally required to agree to every requested restriction.

  • However, if you pay out of pocket in full for a healthcare item or service, you may request that we not disclose information about that item or service to your health plan for payment or healthcare operations.

  • We must honor qualifying requests unless disclosure is required by law.

Request Confidential Communications

  • You may request that we communicate with you through a specific method or at a specific location.

  • For example, you may request that we contact you only through a particular phone number, email address, or mailing address.

  • We will accommodate reasonable requests.

Request an Accounting of Disclosures

  • You may request a list of certain disclosures of your health information made during the six years preceding your request.

  • Some disclosures, including those made for treatment, payment, or healthcare operations, are generally excluded from this accounting.

  • One accounting within a 12-month period is provided without charge. Additional accountings may be subject to a reasonable, cost-based fee as permitted by law.

Receive a Copy of This Notice

  • You may request a paper copy of this Notice of Privacy Practices at any time, even if you previously received it electronically.

Designate a Personal Representative

  • A person legally authorized to act on your behalf may exercise applicable privacy rights for you.

  • We may request documentation verifying that authority before releasing information.

File a Privacy Complaint

  • If you believe your privacy rights have been violated, you may file a complaint with KWH or the U.S. Department of Health and Human Services Office for Civil Rights.

  • We will not retaliate against you for filing a complaint or exercising your privacy rights.

9. Our Legal Responsibilities

Kultivate Women's Health is required by law to:

  • Maintain the privacy and security of your protected health information.

  • Provide you with notice of our privacy practices and legal responsibilities.

  • Follow the terms of the Notice of Privacy Practices currently in effect.

  • Notify affected individuals following a reportable breach of unsecured protected health information.

  • Follow applicable federal and state confidentiality requirements.

We reserve the right to change this notice and make revised provisions effective for the protected health information we maintain, including information collected before the change. When material changes occur, we will update the notice and make the revised version available in our office, on our website, and upon request.
Information disclosed to recipients not subject to HIPAA may be redisclosed by those recipients and may no longer receive HIPAA protection, although other laws may apply.

10. Questions, Requests, or Complaints

If you have questions about this notice, wish to exercise your privacy rights, or want to report a privacy concern, please contact:

Privacy Officer: Ann Konkoly
Kultivate Women's Health LLC
24300 Chagrin Blvd, Suite 103
Beachwood, OH 44122
Phone: (216) 245-3254
Practice Text Line: (216) 877-8879
Email: info@kultivatewomenshealth.com
Website: www.kultivatewomenshealth.com

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights: https://www.hhs.gov/hipaa/filing-a-complaint/

Kultivate Women's Health will not retaliate against anyone for exercising their privacy rights or filing a complaint.