Antidote Health Plan of Ohio, Inc.
Antidote Health Plan of Arizona, Inc.

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.

This notice is effective as of August 29, 2023.

1. About This Notice

This notice applies to members covered under Antidote Health Plan of Ohio, Inc. and Antidote Health plan of Arizona plans. This notice also applies to patients receiving care from members of Antidote’s telehealth provider network (“Telehealth Network”), including Antidote A.I. Health of Florida P.A., Antidote A.I. Health of New Jersey P.C., Antidote A.I. Health of Kansas P.A., Antidote A.I. Health of California P.C., and Antidote Health A.I. of Delaware P.A.. In this notice, the terms "we," "us," "our," and "Antidote" are used to refer to all of these entities.

In this notice, "personal information" refers to any medical or financial information that can be used to identify you and relates to your physical or mental health or condition, the provision of health care to you, or the payment for that care, including your medical record. Personal information may include your name, Social Security number, address, telephone number, employment information, medical history, health records, claims information, or credit card number.

This notice is based on state and federal law. It explains our responsibilities and privacy practices regarding your personal information. We are required to protect the privacy of your personal information, provide you with this notice, and abide by the terms of this notice.

Safeguarding your privacy and the confidentiality of your personal information is a priority. Our policies and procedures are designed to protect your personal information in written, verbal, and electronic forms. Access to your personal information is kept to a minimum for the intended purpose and provided only for legitimate business needs. Physical, electronic, and other safeguards help to protect against unauthorized access to your information.

2. About Antidote and its Telehealth Network

Antidote offers health care coverage to members through individual and group plans. Antidote’s Telehealth Network physicians and other healthcare practitioners also deliver care directly to patients via the Antidote website. Depending on your relationship with us, we may collect, use, and share your information in slightly different ways.

When you apply for health coverage, Antidote may receive your personal information directly from you or third parties, which may include agents, brokers/producers, a trust, or your employer. We may share your personal information with the health plan administrator through which you receive your health benefits, to permit them to manage the business functions of the health plan. For example, we may share health plan enrollment and eligibility information with plan administrators. We may also share information that does not identify specific members with a plan administrator.

If you are enrolled in a self-funded plan through your employer, Antidote may act as an “administrative services organization” for your employer’s self-funded plan and may receive and share information with the plan administrator, usually your employer, for certain administrative activities. For example, we may share claims information for health care services you have received. The plan administrator must confirm that it will protect your personal information by the law.

If you receive services from an Antidote physician or other healthcare practitioner via our telehealth platform, we keep a record of healthcare services you received from us, as well as medical records sent to us from other healthcare providers. While members of Antidote may access care via the Telehealth Network, they are not required to do so. When members choose an Antidote provider outside of the Telehealth Network, that provider may choose to share information with Antidote and/or the Telehealth Network—this helps ensure that Antidote has the most complete medical information to provide you the highest quality care. We will not share your information with others unless directed by you or otherwise allowed or required by law.

3. Your Information

We use and share your personal information to provide treatment, receive and provide payment for health care services, and conduct health care operations. Some examples of how we may use or share your personal information without your authorization are described below. If you do not receive your healthcare from us, some of the following examples may not apply to you.

If you do receive healthcare from us, each time you have a visit with one of our physicians or other healthcare practitioners, we make a record of your visit. Typically, this record contains your symptoms, diagnoses, treatment, a plan for future care or treatment, and billing-related information.

4. Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information for the following purposes:

• Treatment. If you are a patient of an Antidote telehealth provider, or a healthcare provider in Antidote’s provider network, we may use or share your personal information to provide you medical care. For example, our physicians and nurses may share your personal information to provide you health care services. In addition, we may share your personal information with healthcare providers or suppliers outside of Antidote for consultation, referral, or coordination of your care.
• Obtain payment and bill for our services. We may use and share your health information to bill and obtain payment from you for services we provide. We may receive your personal information from healthcare providers who treat you, so we can pay them in accordance with your health benefit plan. In addition, we may disclose your personal information to obtain payment for services provided to you.

Payment purposes could include:

• Determining benefit eligibility and coordinating benefits with other health plans
• Reviewing services for medical necessity
• Paying a claim
• Performing utilization review
• Obtaining premiums
• Subrogating a claim
• Collection activities
• Providing care management
• Underwriting health plan benefits
• Administering and reviewing a health plan
• Determining coverage policies

• Run our organization. We may use and share your health information to onboard you as a patient, run our plan and telehealth provider network, improve your care, and contact you when necessary. We may also use and share your personal information to carry out healthcare operations. Healthcare operations are business activities that support the delivery and payment of health care, which include but are not limited to: educating health or other professionals, conducting medical reviews, providing customer service, performing business planning, arranging for legal and auditing services, or obtaining accreditations and licenses.
• Restrictions on Genetic Information. Please note that we are not allowed to use or share your genetic information for underwriting purposes, to adjust premiums, or to make enrollment or eligibility determinations based on your predisposition to a genetic condition. We are also prohibited from requesting, requiring, or purchasing genetic information about an individual in connection with health plan enrollment.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes.

• To help with public health and safety issues. We can share health information about you for certain situations, including, but not limited to, preventing disease, reporting suspected abuse, neglect, or domestic violence, and/or preventing or reducing a serious threat to anyone’s health or safety.
• To report vital events or registry statistics. We can share health information about you to report vital events, such as births or deaths, or to participate in registries, such as the cancer registry.
• To conduct research. We can use or share your information for health research.
• To comply with the law. We will share information about you if state or federal laws require it.
• Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests.
• To respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
• Business Associates. We may also contract with individuals or entities known as business associates to work on our behalf, which may require us to use and share your personal information with them. Our business associates must agree in writing to safeguard the confidentiality of your personal information in accordance with federal law and this notice.

WE NEVER MARKET OR SELL PERSONAL INFORMATION WITHOUT YOUR CONSENT.

5. Our Responsibilities

• We are required by law to maintain the privacy and security of your health records.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• We are required by law to ask you to sign a written authorization form should we need to release your health records.

6. Your Choices

You may request the following from us:

• Authorization to use or share personal information. Except in the situations described in this notice, we will use and share your personal information only with your written permission or authorization. Antidote is not permitted to sell or rent your personal information and may not use or share your personal information for marketing purposes without your authorization. In some situations, federal and state laws provide special protections for sharing specific kinds of personal information and require authorization from you before we can share that specially protected medical information. For example, information about treatment for alcohol or drug abuse, sexually transmitted diseases or infections, and mental health is specially protected. In these situations, and for any other purpose, we will contact you for the necessary authorization. If you sign an authorization to disclose your health care information, you may withdraw it at any time by letting us know in writing.
• A paper or electronic copy of your medical record. You can ask to see or get a paper or electronic copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, as expeditiously as possible.
• Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within sixty (60) days.
• Confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
• Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. Additionally, if you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for our operations with your health insurer.
• A list of those with whom we have shared information. You can ask for a list (accounting) of the times we have shared your health information for five (5) years before the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within twelve (12) months.
• A copy of this privacy notice. You can ask for a paper copy of this notice at any time. We will provide you with a paper copy promptly.
• 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 make sure the person has this authority and can act for you before we take any action.
• File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting us using the information listed below.

If we are unable to satisfactorily resolve your concern, you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

• For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have the choice to tell us to: (i) Share information with your family, close friends, or others involved in your care; (ii) Share information in a disaster relief situation; and/or (iii) Include your information in a facility directory.

If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In the following cases, we never share your information unless you give us written permission and consent: (i) Marketing to you; (ii) Sale of your information; (iii) Outreach to third-party healthcare vendors; and (iv) Outreach to third-party law firms.

• Health Information Exchanges. We may share your health information electronically with other organizations through a Health Information Exchange (HIE) network. These other organizations may include hospitals, laboratories, health care providers, public health departments, health plans, and other participants. Antidote may participate in several HIE networks with other health care providers outside of Antidote who also have electronic medical record systems. Sharing information electronically is a faster way to get your health information to the health care providers treating you. For example, if you go to a hospital emergency room that participates in the same HIE network as Antidote, the emergency room physicians would be able to access your Antidote health information to help make treatment decisions for you. HIE participants like Antidote are required to meet rules that protect the privacy and security of your health and personal information.
• If your state requires your consent to share personal information with an HIE or your medical record contains certain information (such as from a substance use disorder program) that requires your authorization under state or federal law before information is shared, then Antidote will not release that information to your other treating providers through HIE until you provide authorization.
• In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

7. Notice of Retention and Destruction of Health Records

RETENTION. With certain limited exceptions, we retain your health records for a minimum of seven (7) years following your last encounter with your provider, or as otherwise required under your state’s legal requirements.  

DESTRUCTION. Your records will only be destroyed in a manner that protects your confidentiality, such as by incineration or shredding.

8. Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office. We may change the terms of this notice at any time. If we change any of the privacy practices described in this notice, we will post the revised notice on our website, at www.antidotehealth.com and in our offices.

9. Contact Information

If you have any questions, you can contact us at the address below:

Antidote Health Plan of Ohio, Inc.
Antidote Health plan of Arizona, Inc

ATTN: Legal Department
1460 Broadway
New York, NY 10036
1-866-256-2134

legal@antidotehealth.com