Privacy and HIPAA Compliance Policy

1. Purpose and Scope

The headacheMD for all Foundation (the "Foundation") is committed to protecting the privacy and confidentiality of all personal information, including Protected Health Information (PHI) as defined by HIPAA. This policy establishes procedures for:

Collecting, using, and disclosing PHI in compliance with HIPAA;
Protecting the privacy of all individuals who interact with the Foundation;
Ensuring all staff, volunteers, and business associates comply with privacy requirements;
Responding to privacy concerns and complaints;
Maintaining appropriate safeguards for PHI;
Providing individuals with their rights regarding their health information.

This policy applies to all employees, volunteers, board members, contractors, and business associates who have access to PHI or other personal information.

2. Legal Framework

The Foundation complies with:

HIPAA Privacy Rule (45 CFR Parts 160 and 164): Regulates the use and disclosure of Protected Health Information;
HIPAA Security Rule (45 CFR Part 164): Establishes security standards for electronic PHI;
HIPAA Breach Notification Rule: Requires notification of breaches of unsecured PHI;
State Privacy Laws: Applicable state laws that may provide additional privacy protections;
General Data Protection Principles: Best practices for protecting all personal information.

3. Definitions

3.1 Protected Health Information (PHI)

PHI is individually identifiable health information that is:

Created or received by the Foundation;
Relates to past, present, or future physical or mental health conditions, provision of health care, or payment for health care;
Identifies or could reasonably be used to identify an individual.

PHI includes names, addresses, dates of birth, Social Security numbers, medical record numbers, diagnoses, treatment information, and any other information that could identify a patient.

3.2 Business Associate

A person or entity that performs functions or activities on behalf of the Foundation that involve access to PHI, such as:

Legal counsel;
Accounting firms;
IT service providers;
Document storage companies;
Other contractors who handle PHI.

3.3 Minimum Necessary

The HIPAA requirement to use or disclose only the minimum amount of PHI necessary to accomplish the intended purpose.

3.4 Covered Entity

While the Foundation may not be a traditional "covered entity" under HIPAA, it receives PHI from healthcare providers and must comply with HIPAA requirements when handling such information.

4. Uses and Disclosures of PHI

4.1 Permitted Uses and Disclosures

The Foundation may use and disclose PHI for the following purposes without patient authorization:

Treatment: To coordinate patient assistance and treatment;
Payment: To process payments for patient assistance and verify insurance coverage;
Healthcare Operations: To conduct quality improvement, case management, and other operational activities;
Required by Law: When required by federal, state, or local law;
Public Health: As required for public health reporting (with limitations);
Judicial Proceedings: In response to court orders or subpoenas (with proper safeguards);
Law Enforcement: As required by law (with limitations);
To Prevent Harm: To prevent serious and imminent harm to the patient or others.

4.2 Uses and Disclosures Requiring Authorization

The Foundation must obtain written authorization before using or disclosing PHI for:

Marketing purposes (with limited exceptions);
Sale of PHI;
Most research purposes;
Psychotherapy notes (with limited exceptions);
Any purpose not permitted by HIPAA without authorization.

Authorizations must be specific, written, and signed by the patient or their legal representative.

4.3 Minimum Necessary Standard

When using or disclosing PHI, the Foundation will:

Use only the minimum amount of PHI necessary to accomplish the purpose;
Limit access to PHI to those who need it for their job functions;
Review requests for PHI to ensure they are limited to what is necessary;
Train staff on the minimum necessary standard.

5. Patient Rights

5.1 Right to Access

Patients have the right to:

Access and obtain copies of their PHI maintained by the Foundation;
Receive PHI in the format requested (if readily producible);
Receive access within 30 days (or 60 days with extension notice).

The Foundation may charge a reasonable, cost-based fee for copies.

5.2 Right to Amendment

Patients may request amendments to their PHI if they believe it is inaccurate or incomplete. The Foundation will:

Review amendment requests within 60 days;
Approve amendments if the information is inaccurate or incomplete;
Deny amendments with written explanation and right to appeal;
Notify relevant parties of approved amendments.

5.3 Right to Accounting of Disclosures

Patients may request an accounting of disclosures of their PHI made by the Foundation in the six years prior to the request, except for:

Disclosures for treatment, payment, or healthcare operations;
Disclosures authorized by the patient;
Certain other exceptions specified by HIPAA.

5.4 Right to Request Restrictions

Patients may request restrictions on:

Uses and disclosures of PHI for treatment, payment, or healthcare operations;
Disclosures to family members or others involved in care.

The Foundation will consider all requests but is not required to agree to restrictions.

5.5 Right to Request Confidential Communications

Patients may request that the Foundation communicate with them through alternative means or at alternative locations (e.g., different mailing address, phone number). The Foundation will accommodate reasonable requests.

5.6 Right to File a Complaint

Patients may file a complaint if they believe their privacy rights have been violated. Complaints may be filed with:

The Foundation's Privacy Officer;
The U.S. Department of Health and Human Services Office for Civil Rights.

Patients will not be retaliated against for filing a complaint.

5.7 Right to Receive Notice of Privacy Practices

Patients have the right to receive a copy of the Foundation's Notice of Privacy Practices, which describes how PHI is used and disclosed and outlines patient rights.

6. Administrative Safeguards

6.1 Privacy Officer

The Foundation has designated a Privacy Officer responsible for:

Developing and implementing privacy policies and procedures;
Training staff on privacy requirements;
Receiving and responding to privacy complaints;
Investigating potential privacy violations;
Ensuring compliance with HIPAA and other privacy laws.

6.2 Workforce Training

All employees, volunteers, and board members who have access to PHI must:

Complete HIPAA training upon hire and annually thereafter;
Understand their responsibilities for protecting PHI;
Sign a confidentiality agreement;
Report potential privacy violations immediately.

6.3 Access Controls

The Foundation implements access controls to ensure PHI is accessible only to authorized individuals:

Role-based access controls;
Unique user identification;
Regular review of access permissions;
Immediate revocation of access upon termination.

6.4 Business Associate Agreements

Before sharing PHI with a business associate, the Foundation must:

Execute a written Business Associate Agreement (BAA);
Ensure the BAA requires the business associate to safeguard PHI;
Monitor business associate compliance;
Terminate agreements if violations occur.

7. Physical Safeguards

The Foundation implements physical safeguards to protect PHI:

Facility Controls: Secure offices with locked doors and restricted access;
Workstation Security: Locked file cabinets, secure storage for paper records;
Device Controls: Secure disposal of devices containing PHI;
Media Controls: Secure storage and disposal of backup media, CDs, and other storage devices.

8. Technical Safeguards

The Foundation implements technical safeguards for electronic PHI:

Access Control: Unique user IDs, passwords, and multi-factor authentication;
Encryption: Encryption of PHI in transit and at rest;
Audit Controls: Logging and monitoring of access to PHI;
Transmission Security: Secure methods for transmitting PHI electronically;
Backup and Recovery: Secure backup systems with encryption;
Firewalls and Security Software: Up-to-date security software and firewalls.

9. Breach Notification

9.1 Breach Definition

A breach is the acquisition, access, use, or disclosure of PHI in a manner not permitted by HIPAA that compromises the security or privacy of the PHI.

9.2 Breach Assessment

Upon discovery of a potential breach, the Foundation will:

Immediately investigate the incident;
Assess whether a breach occurred;
Determine if the breach poses a low probability of compromise (which may not require notification);
Document the assessment and findings.

9.3 Notification Requirements

If a breach of unsecured PHI is confirmed, the Foundation will:

Notify Affected Individuals: Within 60 days of discovery, by first-class mail (or email if preferred);
Notify HHS: For breaches affecting 500+ individuals, within 60 days; for smaller breaches, within 60 days of year-end;
Notify Media: For breaches affecting 500+ individuals in a state or jurisdiction, notify prominent media outlets;
Provide Required Information: Description of breach, types of PHI involved, steps individuals should take, what the Foundation is doing, and contact information.

9.4 Breach Response Plan

The Foundation maintains a breach response plan that includes:

Immediate containment of the breach;
Assessment and investigation procedures;
Notification procedures and timelines;
Remediation steps;
Documentation requirements.

10. Notice of Privacy Practices

The Foundation maintains a Notice of Privacy Practices that:

Describes how PHI may be used and disclosed;
Outlines patient rights;
Explains the Foundation's legal duties;
Provides contact information for privacy concerns;
Is provided to patients at the first service delivery or upon request.

11. Non-Health Information Privacy

For information that is not PHI (such as donor information, website visitors, etc.), the Foundation:

Collects only necessary information;
Uses information only for stated purposes;
Protects information with appropriate security measures;
Does not sell or share personal information with third parties without consent (except as required by law);
Allows individuals to opt-out of marketing communications;
Maintains secure websites with encryption for sensitive transactions.

12. Compliance and Enforcement

12.1 Violations

Violations of this policy may result in:

Disciplinary action, up to and including termination;
Legal action if violations involve illegal conduct;
Reporting to regulatory authorities when required;
Civil or criminal penalties under HIPAA.

12.2 Monitoring and Auditing

The Foundation will:

Conduct regular audits of PHI access and use;
Review privacy practices annually;
Investigate all privacy complaints;
Take corrective action when violations are identified.

13. Policy Review and Updates

This policy will be reviewed annually and updated as necessary to reflect changes in:

HIPAA regulations and guidance;
State privacy laws;
Foundation operations;
Best practices in privacy protection.

Material changes to this policy will be communicated to all staff and, when required, to patients.

14. Contact Information

For privacy concerns, questions, or to exercise your rights, contact:

headacheMD for all Foundation
Privacy Officer
Email: privacy@headacheMD.org
Phone: (713) 426-3337
Address: 19907 Empress Crossing Ct, Spring, TX 77379

To file a complaint with HHS:
U.S. Department of Health and Human Services
Office for Civil Rights
Website: www.hhs.gov/hipaa/filing-a-complaint
Phone: 1-800-368-1019