Triangle Longevity Clinic (operated by Suneha Sundaram, MD PLLC)
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.
Triangle Longevity Clinic (operated by Suneha Sundaram, MD PLLC) (the “Clinic,” “we,” “us,” or “our”) is required by law to maintain the privacy of your protected health information (“PHI”), to provide you with this Notice of our legal duties and privacy practices with respect to your PHI, to notify you following a breach of your unsecured PHI, and to follow the terms of this Notice while it is in effect.
This Notice applies to all records of your care and billing generated by the Clinic, whether created before or after the Effective Date above, and to any other health care provider who may provide care to you at the Clinic.
The following categories describe ways we are permitted by law to use and disclose your PHI without first obtaining your written authorization. Not every use or disclosure in a category is listed, but all of the ways we are permitted to use and disclose your information fall within one of these categories.
We may use and disclose your PHI to provide, coordinate, or manage your care and related services. For example, we may share information about your hormone therapy, peptide therapy, supplement plan, or test results with an outside laboratory performing testing you requested, a pharmacy filling your prescription, or another physician involved in your care.
We may use and disclose your PHI to bill and collect payment for the services you receive, including processing membership fees, sending statements, or, at your request, providing documentation you can submit to your own insurer.
We may use and disclose your PHI for activities necessary to run the Clinic and support treatment and payment, such as quality assessment, staff training, compliance activities, and business planning.
We may use your PHI to contact you with appointment reminders, or to tell you about treatment alternatives or health-related services that may interest you, consistent with any communication preferences you have given us.
We may share PHI with a family member, friend, or other person you identify who is involved in your care or helps pay for it, to the extent relevant to that person’s involvement. If you are present, we will give you the opportunity to object first. If you are not present or are unable to agree, we may share information if, in our professional judgment, doing so is in your best interest. We may also use or disclose PHI to notify, or assist in notifying, a family member or personal representative of your location or general condition, including to disaster relief organizations.
We will disclose your PHI when required to do so by federal, state, or local law.
We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person.
We may disclose PHI for public health activities (such as reporting certain diseases or adverse events); to health oversight agencies for activities authorized by law (such as audits, investigations, and licensure); and in response to a court or administrative order, subpoena, or discovery request, as permitted by law.
We may disclose PHI to law enforcement officials as permitted by law, and to coroners, medical examiners, or funeral directors as necessary for them to carry out their duties.
We may disclose PHI to organ and tissue procurement organizations; to researchers when the research has been approved through an appropriate privacy oversight process; and, if applicable, to military authorities or for national security purposes as required by law.
We may disclose PHI as authorized by, and to the extent necessary to comply with, workers’ compensation or similar programs.
We may share PHI with companies that perform services on our behalf (for example, our electronic health record, telehealth platform, billing platform, or IT vendors). These business associates are required by written contract to protect your information consistent with HIPAA.
Other than as described above, we will not use or disclose your PHI without your written authorization. This includes, in particular:
If you give us written authorization, you may revoke it in writing at any time, except to the extent we have already relied on it.
Where North Carolina or other federal law provides greater privacy protection than HIPAA for certain information, we follow the more protective standard. For example:
You have the right to inspect and obtain a copy, including an electronic copy, of your PHI that we maintain, with limited exceptions. We may charge a reasonable, cost-based fee as permitted by law. Requests should be made in writing to our Privacy Officer.
You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. We may decline in certain circumstances permitted by law and will explain our reasons in writing.
You have the right to request a list of certain disclosures of your PHI we have made, other than disclosures for treatment, payment, health care operations, and certain other excluded categories.
You have the right to ask us to restrict how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree, except that we must agree to a restriction on disclosure to a health plan for payment or operations (not treatment) when the disclosure relates solely to a service you paid for in full, out of pocket.
You have the right to request that we communicate with you in a certain way or at a certain location (for example, only by mail, or only at a specific phone number).
You have the right to a paper copy of this Notice at any time, even if you agreed to receive it electronically.
If you have given someone medical power of attorney or someone is your legal guardian, that person may exercise your rights and make choices about your PHI.
You have the right to be notified if a breach of your unsecured PHI occurs.
We reserve the right to change this Notice and to make the revised Notice effective for PHI we already have as well as information we receive in the future. We will post the current Notice in our office and on our website and make it available upon request.
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.
| Contact | Information |
|---|---|
| Privacy Officer | Suneha Sundaram, MD |
| Address | Triangle Longevity Clinic, 135 Parkway Office Ct, Ste 104, Cary, NC 27518 |
| Phone | (984) 833-2815 |
| admin@trianglelongevityclinic.com |
Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201. Toll-free: 1-800-368-1019; TDD: 1-800-537-7697; Email: OCRComplaint@hhs.gov; Online: ocrportal.hhs.gov/ocr/cp.
If you have questions about this Notice or our privacy practices, please contact our Privacy Officer using the information above.
This web version contains the full text of the document. Signature, initial and checkbox lines are left out here and appear on the signable copy given to you at enrollment.
