Notice of HIPAA Privacy Practices
Last updated: November 1, 2021
This notice describes how medical information about you may be used and disclosed by Polygon Technologies, Inc. (“Polygon”) and Polygon Psychology Group, Inc. (“PPG”) (collectively, unless otherwise referred to herein individually, the “Companies”, “we”, “us”), and how you can get access to this information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”), requires us to ask each of our clients to acknowledge receipt of our Notice of HIPAA Privacy Practices (the “Notice”). The Notice is published on the Polygon website. You acknowledge receipt of the Notice by clicking on the “I Acknowledge Receipt of the Notice of HIPAA Privacy Practices” button, or by indicating your acknowledgement in another written or digital manner provided. You can receive a copy of the Notice by printing one from our website or by contacting the Privacy Officer by writing to: Privacy Officer, Polygon, 8605 Santa Monica Blvd, Suite 56386, West Hollywood, California 90069 or sending an email to privacy@hellopolygon.com.
The Companies are dedicated to maintaining the privacy of your protected health information (“PHI”). PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present or future physical or mental health or condition, (b) the provision of healthcare to you, or (c) your past, present, or future payment for the provision of healthcare. In conducting their businesses, the Companies will receive and create records containing your PHI. The Companies are required by law to maintain the privacy of your PHI, to provide you with notice of their legal duties and privacy practices with respect to your PHI, and to notify you in the case of a breach or unsecured PHI.
The Companies must abide by the terms of the Notice while it is in effect. This current Notice will remain in effect until the Companies replace it. The Companies reserve the right to change the terms of the Notice at any time, as long as the changes are in compliance with applicable law. If the Companies change the terms of the Notice, the new terms will apply to all PHI that they maintain, including PHI that was created or received before such changes were made. If the Companies change the Notice, they will post the new Notice on its/their website and will make the new Notice available upon request. The date of the last update will be clearly indicated at the top of the Notice. Please review the Notice from time to time to ensure you are familiar with our HIPAA privacy practices.
Uses and Disclosures of PHI That Do Not Require Your Authorization
The Companies use and disclose PHI in a number of ways connected to your treatment, payment for your care, and our healthcare operations. Some examples of how we may use or disclose your PHI without your authorization are listed below.
Treatment. The Companies may disclose your PHI to Polygon Provider psychologists for the performance of tests and to them and other healthcare providers in connection with the provision of follow-up services.
Payment. The Companies may use and disclose your PHI to bill you for a test and any follow-up services, to pay Polygon Providers, to other organizations for payment activities, and to your health insurer, health plan or health care account in connection with assisting you in seeking reimbursement for some part or all of the cost of the test and any follow-up services.
Healthcare operations. The Companies may use and disclose your PHI in connection with their healthcare operations, such as providing client services, conducting quality review tests, data aggregation, reviewing and improving our services, and training. The Companies may engage third parties to provide various services for the Companies. If any such third party must have access to your PHI in order to perform its services, the Companies will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in the Notice.
Special circumstances. The following categories describe unique circumstances in which we may use or disclose your PHI:
As required by law. The Companies may use and disclose your PHI to the extent required by law.
Public health activities. The Companies may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence, and reporting to the Food and Drug Administration regarding the quality, safety, and effectiveness of a regulated product or activity. The Companies may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
Minors. In general, parents and legal guardians are legal representatives of minor clients. However, in certain circumstances, as dictated by state law, minors can act on their own behalf and consent to their own treatment. In general, the Companies will share the PHI of a client who is a minor with the minor’s parents or guardians, unless the minor could have consented to the care themselves (except where parental disclosure may be required per applicable law).
Workers’ compensation. The Companies may disclose your PHI as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries.
Health oversight activities. The Companies may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.
Judicial and administrative proceedings. The Companies may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.
Law enforcement. The Companies may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person, or to report a crime or provide information concerning victims of crimes.
Decedents. The Companies may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.
Organ procurement. The Companies may, under certain circumstances, use or disclose PHI for the purposes of organ donation and transplantation.
Financial information. The Companies may ask you about income or other financial information to determine if you may qualify for a low income waiver or reduction of the fees for test or follow-up services. The Companies may use this information for operations, marketing, and administrative purposes and to improve our service offerings.
Research. The Companies may, under certain circumstances, use or disclose PHI for research purposes, subject to the confidentiality provisions of state and federal law.
Threat to health or safety. The Companies may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Specialized government functions. The Companies, may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. The Companies may also disclose PHI to federal officials for intelligence and national security purposes.
Miscellaneous circumstances. We may also use or disclose your PHI without your authorization in the following circumstances:
Contacting you directly. The Companies may use your PHI, including your email address or phone number, to contact you. For example, the Companies may use this information to send you appointment reminders and other communications relating to your care and treatment, or let you know about treatment alternatives or other health related services or benefits that may be of interest to you.
Your client account. The Companies may make certain PHI, such as information about care or treatment, appointment histories, and test reports, accessible to you through secured online tools, such as your Polygon account.
Family and friends. The Companies may disclose PHI to a member of your family, a relative, a close friend — or any other person you identify who is directly involved in your healthcare — when you are either not present or unable to make a healthcare decision for yourself and we determine that disclosure is in your best interest. The Companies will also assume that we may disclose PHI to any person you permit to be physically present with you during Test Appointments or Follow-Up Appointments.
De-identified information. The Companies may use or disclose PHI if information is removed from your PHI so that you can’t be identified, except as prohibited by law.
Uses and Disclosures of Your PHI That Require Us to Obtain your Authorization
Except in the situations listed in the sections above, the Companies will use and disclose your PHI only with your written authorization. You may revoke any such authorization at any time. This means we will not use your PHI in the following cases, unless you give us written permission:
Marketing purposes, except as allowed by HIPAA or applicable law (by way of example, marketing communications allowed by HIPAA without authorization include communications pertaining to care or treatment and/or our products or services)
Sale of your information
Sharing your PHI with your employer or school
Most sharing of psychotherapy notes
In some situations, federal and state laws provide special protections for specific kinds of PHI and require authorization from you before we can disclose that specially protected PHI. For example, additional protections may apply in some states to genetic, mental health, drug and alcohol abuse, rape and sexual assault, sexually transmitted disease and/or HIV/AIDS-related information, and/or to the use of your PHI in certain review and disciplinary proceedings of healthcare professionals by state authorities. In these situations, we will comply with the more stringent state laws pertaining to such use or disclosure. If you have questions about these laws, please contact the Privacy Officer at privacy@hellopolygon.com.
Your Rights Regarding Your PHI
You have the following rights regarding the PHI maintained by the Companies:
Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that the Companies restrict their disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to The Companies. The Companies are not required to comply with your request, except when a restriction has been requested regarding a disclosure to a health insurer or plan in situations where you have paid for services in full and where the purpose of the disclosure is for payment. However, if the Companies agree to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency. To submit such a request, complete a Restriction Request Form, which you can obtain by contacting privacy@hellopolygon.com, and mail it to the address listed on the form or submit it to privacy@hellopolygon.com.
Confidential communication. You have the right to receive confidential communications of your PHI. You may request that we communicate with you by another means. For example, if you want us to communicate with you at a different address, we can usually accommodate that request. We may ask that you make your request to us in writing by sending an email to privacy@hellopolygon.com. We will agree to reasonable requests.
Inspection and copies. You have the right to inspect or receive an electronic or paper copy of your PHI. You must submit your request in writing to the Companies. The Companies may impose a reasonable fee for the costs of copying, mailing, labor and supplies associated with your request. The Companies may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, the Companies will inform you of the reason for the denial, and you may request a review of the denial. To request access to your PHI that is not already accessible to you in your account, complete a Medical Records Request Form, which you can obtain by contacting privacy@hellopolygon.com, and mail it to the address listed on the form or submit it to privacy@hellopolygon.com.
Disclosure to a third party. To authorize the Companies to disclose your PHI to a third party, complete a Medical Records Request Form, which you can obtain by contacting privacy@hellopolygon.com, and mail it to the address listed on the form or submit it to privacy@hellopolygon.com.
Amendment. You have a right to request that the Companies amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by the Companies. You must submit your request in writing to the Companies and provide a reason to support the requested amendment. The Companies may, under certain circumstances, deny your request by sending you a written notice of denial. If the Companies deny your request, you will be permitted to submit a statement of disagreement for inclusion in your records. To make a request to amend PHI that you cannot otherwise change yourself through your account, complete an Amendment Form, which you can obtain by contacting privacy@hellopolygon.com, and mail it to the address listed on the form or submit it to privacy@hellopolygon.com.
Accounting of disclosures. You have a right to receive an accounting of all disclosures the Companies have made of your PHI. However, that right does not include disclosures made for treatment, payment or healthcare operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures as permitted by law. You must submit your request in writing to the Companies and you must specify the time period involved (which must be for a period of time no more than six years before the date of the request). Your first accounting will be free of charge. However, the Companies may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. The Companies will inform you of such costs in advance, so that you may withdraw or modify your request to save costs. o make a request for an accounting of disclosures, complete an Accounting of Disclosures Form, which you can obtain by contacting privacy@hellopolygon.com, and mail it to the address listed on the form or submit it to privacy@hellopolygon.com.
Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will confirm the person has the authority and can act for you before we take any action.
Breach notification. You have the right to be notified in the event that The Companies (or a Business Associate of the Companies) discovers a breach of unsecured PHI.
Paper copy. You have the right to obtain a paper copy of the Notice from the Companies at any time upon request. To obtain a paper copy of the Notice, print a copy from our website, or contact the Privacy Officer by writing to: Privacy Officer, Polygon, 8605 Santa Monica Blvd, Suite 56386, West Hollywood, California 90069 or sending an email to privacy@hellopolygon.com.
Complaint. You may complain to the Companies and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with the Companies, you must submit a statement in writing to: Privacy Officer, Polygon, 8605 Santa Monica Blvd, Suite 56386, West Hollywood, California 90069 or sending an email to privacy@hellopolygon.com. To file a complaint with the Secretary send a letter to 200 Independence Ave, S.W., Washington, D.C. 20201, call (877) 696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints. The Companies will not retaliate against you for filing a complaint.
Further information. If you would like more information about your privacy rights, please send an email to the Privacy Officer at privacy@hellopolygon.com.
Communication Platforms
If you choose to communicate with us via emails, texts or chats, you acknowledge that we may exchange PHI with you via email, text or chat, that email, text and certain chat functionality may not be a secure method of communication, and that you agree to the security risks of such communication. If you would prefer not to exchange PHI via email, text or chat, you can choose not to communicate with us via those means, and you can notify us at privacy@hellopolygon.com.
Contact Information
If you have any questions or comments about the Notice, the ways in which we collect and use your PHI, or your choices and rights regarding such collection and use, please do not hesitate to contact the Privacy Officer at:
Email: privacy@hellopolygon.com
Phone: (213) 712-5727
Address: Polygon, 8605 Santa Monica Blvd, Suite 56386, West Hollywood, California 90069