ImproveAbility LLC HIPAA Notice of Privacy Practices

 Effective Date: 6/9/2020

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

The terms of this Notice of Privacy Practices (“Notice”) apply to ImproveAbility LLC, its affiliates and its employees. ImproveAbility LLC will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. We are required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. 

We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by ImproveAbility LLC. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below. 

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION: 

Authorization and Consent: Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. 

Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc. 

Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment. 

Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving clinical treatment and patient care. 

Individuals Involved In Your Care: We may from time to time disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. 

Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information. 

Appointments and Services: We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. With such a request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such requests. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below. 

Research: In limited circumstances, we may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of your information. 

Fundraising: We may use your information to contact you for fundraising purposes. We may disclose this contact information to a related foundation so that the foundation may contact you for similar purposes. If you do not want us or the foundation to contact you for fundraising efforts, you must send such a request in writing to the Privacy Officer at the address below. 

Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following: 

  • Any purpose required by law; 
  • Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations; 
  • If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect or domestic violence; 
  • To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls; 
  • To your employer when we have provided health care to you at the request of your employer; 
  • To a government oversight agency conducting audits, investigations, civil or criminal proceedings; 
  • Court or administrative ordered subpoena or discovery request; 
  • To law enforcement officials as required by law if we believe you have been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law; 
  • To coroners and/or funeral directors consistent with law; 
  • If necessary to arrange an organ or tissue donation from you or a transplant for you; 
  • If you are a member of the military, we may also release your protected health information for national security or intelligence activities; and 
  • To workers’ compensation agencies for workers’ compensation benefit determination. 

DISCLOSURES REQUIRING AUTHORIZATION:

Psychotherapy Notes: We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which we may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public. 

Genetic Information: We must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment or health care operations purposes. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law. 

Marketing: We must obtain your authorization for any use or disclosure of your protected health information for marketing, except if the communication is in the form of (1) a face-to-face communication with you, or (2) a promotional gift of nominal value. 

Sale of Protected Information: We must obtain your authorization prior to receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for: 

  • Public health activities; 
  • Research purposes, provided that we receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes; 
  • Treatment and payment purposes; 
  • Health care operations involving the sale, transfer, merger or consolidation of all or part of our business and for related due diligence; 
  • Payment we provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on our behalf (or the subcontractor undertakes on behalf of a business associate) and the only remuneration provided is for the performance of such activities; 
  • Providing you with a copy of your health information or an accounting of disclosures; 
  • Disclosures required by law; 
  • Disclosures of your health information for any other purpose permitted by and in accordance with the Privacy Rule of HIPAA, as long as the only remuneration we receive is a reasonable, cost-based fee to cover the cost to prepare and transmit your health information for such purpose or is a fee otherwise expressly permitted by other law; or 
  • Any other exceptions allowed by the Department of Health and Human Services. 

RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION: 

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made in writing and signed by you or your legal representative. You may obtain a “Patient Access to Health Information Form” from the front office person. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies you will be charged a fee for copying and postage. 

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make requested amendments, but we will give each request careful consideration. All amendment requests must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an “Amendment Request Form” from the front office person or individual responsible for medical records. 

Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. “Accounting Request Forms” are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request. 

Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. We are not required to agree to most restriction requests, but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid ImproveAbility LLC in full. If we agree to any discretionary restrictions, we reserve the right to remove such restrictions as we appropriate. We will notify you if we remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records. 

Right to Notice of Breach: We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself. 

Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to the Privacy Officer at the address below. 

Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint. 

Office for Civil Rights 

Department of HHS 

Jacob Javits Federal Building 

26 Federal Plaza – Suite 3312 

New York, NY 10278 

Voice Phone (212) 264-3313 

FAX (212) 264-3039 

TDD (212) 264-2355 

For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the ImproveAbility LLC Privacy Officer by phone at (512) 522-1705 or at the following address: 

ImproveAbility LLC

3310 W. Braker Ln.

Unit 300-142

Austin, TX 78758

This Notice of Privacy Practices is also available on our ImproveAbility LLC web page at www.improveability.com. 

ImproveAbility LLC

Non-Discrimination Policy

 Effective Date: 6/9/2020 and 4/7/2022

Acceptance of Patients/Clients for Service

Effective Date: June 30, 2021

Policy

ImproveAbility accepts clients whose needs can be met by the services that ImproveAbility provides. ImproveAbility provides services in a timely manner. Patients/clients who meet the following criteria are eligible for acceptance for services:

  • The client resides in the company’s geographic area of service.
  • The client matches the target population served.
  • The required equipment, service, or supply needed is within the company’s scope of services.
  • Qualified staff members are available to deliver or provide the product or service requested.
  • The necessary equipment and supplies are available.
  • Payment arrangements are acceptable to ImproveAbility.
  • If required – the client is under a physician’s care, and the physician provides the required written orders and documentation.
  • The client agrees to operate equipment safely and comply with the physician’s orders (if required).
  • The equipment may be safely placed in the client residence.
  • The equipment or care the client requires conforms with ImproveAbility policies and standards.

ImproveAbility uses standardized processes for:

  • Timely intake and acceptance of referrals or requests for service
  • Informing clients of acceptance or denial
  • Validating client eligibility for services
  • Verification of client benefits to be used for payment (if required)
  • Verification of the receipt of the items or services by client
  • Provides for appropriate and informed termination of equipment or services to a client
  • Maintaining client dignity, privacy, and respect
  • Ensures that all staff respect client property while providing services in client residence
  • The organization provides a loan or replacement of any equipment or device in the event of failure, breakage, or questionable performance for any item on loan to a client
  • Informing in a timely manner referral source (and physician if required) if item/service cannot be provided as ordered, but in no case more than five (5) calendar days, if it cannot provide the equipment, items or services that are prescribed for a client
  • Timely follow-up as needed consistent with the types of equipment, items and service(s) provided, and recommendations from the prescribing physician or healthcare team members

In addition, ImproveAbility complies with all Federal, state, and local anti-discrimination laws when accepting clients for service. Eligibility for acceptance for services is not based on age, sex, race, nationality, ancestry, creed, sexual orientation, disability, diagnosis/infectious disease, or do-not-resuscitate status.

Informing Clients of acceptance or denial

Effective Date: June 30, 2021

Policy

Staff trained in ImproveAbility’s scope of services and acceptance criteria are designated to receive referrals for acceptance for service. When a client does not meet the acceptance criteria, or has service needs that cannot be met by ImproveAbility, the client may be transferred or referred to another agency (see section PS 1f of this policy for more information). ImproveAbility declines all referrals or orders for equipment or services that are inconsistent with standard medical practice, physician orders, payer requirements, and ImproveAbility’s company policy.

Procedure

Following are the recommended steps for handling referrals:

  • Start a job in ImproveAbility’s customer management system consistent with the service or device the client or referral source is recommending.
    • Each pipeline has a defined workflow in which all pertinent employees are trained.
  • Obtain insurance information (when necessary), directions to the client home when necessary, and make delivery arrangements.
  • Prepare all necessary paperwork, and complete it with the client and/or the caregiver.
  • Arrange a delivery time.
  • Mail or deliver relevant documents (e.g., Certificate of Medical Necessary) to the physician to complete – if required.
  • Place physician orders in the patient’s/client’s file – if physician’s order is required for the desired service or device.
  • Maintain a list of other companies and their services for referrals in the event that ImproveAbility is unable to provide services.

PS 1c Validation of client eligibility for services

Effective Date: June 30, 2021

Policy

At the time of acceptance, ImproveAbility collects information about the client for the purposes of billing and delivery of services, collects physician information (if necessary), and confirms the patient’s/client’s eligibility for coverage from the third-party payer (if necessary).

ImproveAbility will ensure that clients are eligible for services based on payer source criteria.  ImproveAbility will not provide items or services to clients not eligible for services as per payer source guidelines.

Procedures

ImproveAbility will gather all relevant client information, insurance information, and third-party payer information at the time of intake.  When this information is gathered, appropriate payer sources are contacted to verify eligibility and benefits.

As soon as possible, clients and referral sources will be kept informed of client eligibility for services.

Verification of client receipt of items or services

Effective Date: June 30, 2021

Policy

Items are delivered to clients in one of three ways:

  1. In person by a representative of ImproveAbility,
  2. Remote training via video call,
  3. Mailed to a service provider (such as a speech therapist) in order for the service provider to physically deliver a device to the client, or
  4. Mailed to the client’s home.

Procedures

When ImproveAbility delivers, installs, and provides training to clients in person the ImproveAbility representative present at the delivery has the client sign an invoice verifying receipt of all items on the invoice.  At times, ImproveAbility will perform training on provided software or the use of hardware via video call.  In this case, the client will be emailed an invoice denoting the service provided and they will electronically sign that invoice.  When items are mailed to a client or service provider they may or may not be delivered with signature required.  In either case, ImproveAbility retains a copy of the proof of delivery from the shipping company in the client’s electronic file.

Validation of Payer and Client Benefits

Effective Date: June 30, 2021

Policy

ImproveAbility will verify all payers and client benefits prior to providing any item or service.

Procedure

If insurance benefits will be billed as part of a client’s job, then ImproveAbility will independently verify that a client’s insurance coverage is active and current.  If pre-approval for items or services is needed for an insurance claim, then ImproveAbility will obtain the needed pre-approval prior to providing any item or service.  If third party payers (such as a charity) will be paying all or a portion of the items or services, then ImproveAbility will obtain pre-approval from that third party in writing stating how much of the cost of the item or service they will cover.

Clients will be kept informed of all payment responsibilities and expected amounts throughout their process with ImproveAbility.

Admission, Transfer, Termination, and Discharge Process

Effective Date: June 30, 2021

Admission and Transfer:

Policy

Staff trained in ImproveAbility’s scope of services and acceptance criteria are designated to receive referrals for acceptance for service. ImproveAbility declines all referrals or orders for equipment or services that are inconsistent with standard medical practice, physician orders, payer requirements, and ImproveAbility’s company policy.

When a client does not meet the acceptance criteria, or has service needs that cannot be met by ImproveAbility, the client may be transferred or referred to another agency.

Admission Procedure

Following are the recommended steps for admitting new clients:

  • Start a job in ImproveAbility’s customer management system consistent with the service or device the client or referral source is recommending.
    • Each pipeline has a defined workflow in which all pertinent employees are trained.
  • Obtain insurance information (when necessary), directions to the client home when necessary, and make delivery arrangements.
  • Have client fill out any necessary paperwork for billing purposes if the client will be libel for any or all of the cost of the items or services.
  • Keep client and referral source informed of the progress of each job as required.

Transfer Procedure

When necessary, clients will be transferred to other providers.  The following is a list of providers and what they provide to refer to when a client is asking for an item or service ImproveAbility does not provide.  This list will be reviewed annually and updated as needed.

Company Name and Contact InformationType of items provided
Travis Medical   512-458-4589 www.travismedical.comPediatric Rehab Equipment   -Wheelchairs, standers, other positioning equipment Custom Rehab Equipment -Wheelchairs, gait trainers, standers, custom seating and positioning Disposable Supplies Hospital Beds
United Access   1-877-579-1141 https://www.unitedaccess.com/Vehicle Modifications   Accessible Vehicles Handicap Driving Aids Mobility Scooters
STAP Provider List   512-438-4880https://www.staptexas.org/Login/vendorsearchrpt.aspx

Termination and Discharge Policy

Clients may be terminated from service for several reasons. Terminations are conducted in a manner that is the least harmful for the client. The client, along with his/her physician, receives any necessary written or verbal instructions including recommendations for future care. Documentation related to the termination/discontinuation of service is filed in the client’s medical record.

Following are situations in which a client may be terminated from services:

  • Physician discontinues the equipment/service.
  • A physician order cannot be obtained.
  • Orders are not consistent with acceptable medical practice.
  • ImproveAbility no longer offers the equipment/service.
  • Client needs equipment/services ImproveAbility does not provide.
  • Therapy/service is complete and goals are met.
  • Client moves out of the service area.
  • Client does not operate equipment safely or is noncompliant (e.g., continues to smoke when oxygen is in use).
  • Employee safety is threatened.
  • Client chooses to transfer to another company.
  • Client is no longer eligible for the item/service based on payer source criteria.
  • Client buys the equipment.
  • Client refuses treatment/equipment and physician is notified.
  • Client has no source of funding and indigent care services are not available.
  • Client dies.

Procedures

Once a client is scheduled to be discharged, a qualified company employee undertakes the following:

  • Assess the client to determine any continuing care needs.
  • Provides the client relevant information about additional resources.
  • Provide pertinent client information to the receiving organization (if applicable) and physician after obtaining a signed authorization to release medical information form.
  • Documents all communication and the reason for discharge in the client record.

Client Dignity and Client Privacy and Respect for Client Property

Effective Date: June 30, 2021

Policy

ImproveAbility instructs all staff members in the importance of respecting property, confidentiality, and security of our clients whether in the client residence or on the telephone. In addition, ImproveAbility educates all staff members in the importance of respecting each client’s property.

Procedure

All staff members are oriented to issues of dignity and respect for the client. Religious or cultural beliefs and background, or other issues of diversity are recognized, respected, and are considered when providing care, services and supplies for clients.

All staff members are trained to respect the client’s home and items inside the home.  ImproveAbility has the expectation that any trash generated from a delivery or any mess caused by a delivery will be addressed by the employee before leaving the home.

PROCEDURE FOR COMMUNICATION WITH PERSONS OF LIMITED ENGLISH PROFICIENCY

Effective Date: April 7, 2022

Policy:

It is the policy of ImproveAbility LLC to provide communication aids (at no cost to the person being served) to Limited English Proficient (LEP) persons, including current and prospective patients, clients, family members, interested persons, et al., to ensure them a meaningful opportunity to apply for, receive or participate in, or benefit from the services offered. The procedures outlined below will reasonably ensure that information about services, benefits, consent forms, waivers of rights, financial obligations, etc., is communicated to LEP persons in a language which they understand. Also, they will provide for an effective exchange of information between staff/employees and patients/clients and/or families while services are being provided.

Procedure:

  1. ImproveAbility LLC will designate the Administrative Associate to be responsible for implementing methods of effective communication with LEP persons.
  2. The Administrative Associate will:
  • Maintain and routinely update a list of all bilingual persons, organizations, and staff members who are available to provide bilingual services, and
  • Develop written instructions on how to gain access to these services, i.e., contact persons, telephone numbers, addresses, languages available, hours available, fees and conditions under which the person(s) are available.
    • Post a short “tagline” written in at least the top 15 languages spoken by individuals with limited English proficiency in relative state informing that language assistance service is free of charge.
  1. In order to ensure effective communication and to protect the confidentiality of client information and privacy, the client will be informed that the services of a qualified interpreter are available to him/her at no additional charge. Only after having been so informed, the client may choose to rely on a family member or friend in an emergency situation. The choice of the client and presence of an interpreter will be documented after every visit.

– Use a translator when translating written content in paper or electronic form.

SECTION 504 NOTICE OF PROGRAM ACCESSIBILITY

Effective Date: April 7, 2022

The regulation implementing Section 504 requires that an agency/provider/vendor “shall adopt and implement procedures to ensure that interested persons, including persons with impaired vision or hearing, can obtain information as to the existence and location of services, activities, and facilities that are accessible to and usable by disabled persons.” (45 C.F.R. §84.22(f))

Access Notice 

This provider and all of its programs and activities are accessible to and usable by disabled persons, including persons with impaired hearing and vision.

Access features include:

  • Convenient off-street parking designated specifically for disabled persons.
  • Curb cuts and ramps between parking areas and buildings.
  • Level access into the first-floor level.
  • Fully accessible offices, meeting rooms, bathrooms, and public waiting areas.

ImproveAbility makes every effort possible to provide persons with impaired hearing, vision, speech, or manual skills, auxiliary aids without additional charge for such aids.

If you require any of the aids listed above, please let the Administrative Associate know.

Policy

Staff trained in ImproveAbility’s scope of services and acceptance criteria are designated to receive referrals for acceptance for service. When a client does not meet the acceptance criteria, or has service needs that cannot be met by ImproveAbility, the client may be transferred or referred to another agency (see section PS 1f of this policy for more information). ImproveAbility declines all referrals or orders for equipment or services that are inconsistent with standard medical practice, physician orders, payer requirements, and ImproveAbility’s company policy.