THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

I. PROTECTED HEALTH INFORMATION:

The Provider understands that health information about You and your health care is personal. The Provider is committed to protecting health information about You. This notice applies to all of Patient’s protected health information pursuant to HIPAA and any state counterpart (“PHI”). This notice will tell You about the ways in which the Provider may use and disclose  PHI. Provider is required by law to:

 

• Make sure that PHI that identifies You is kept private except in certain circumstances.

• Give You this notice of Provider’s legal duties and privacy  practices with respect to PHI.

• Follow the terms of the notice that is currently in effect.

 

Please note that Provider can change the terms of this Notice from time to time in compliance with law and such changes will apply to all information I have about You. The new Notice will be available upon request  and on Provider’s website.

 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose  PHI.

 

For Treatment, Payment, or Health Care Operations: Federal privacy  rules and regulations allow health care providers who have direct treatment relationship with the patient/client to use or disclose  the patient/client’s PHI without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. Provider may also disclose  PHI for the treatment activities of any health care provider. This too can be done without Patient’s written authorization. For example, if a clinician  were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose  your PHI in order to assist the clinician  in diagnosis  and treatment of Patient’s mental health condition.

 

Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record  and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things,  the coordination and management of

health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. 

 

Lawsuits and Disputes:  Provider may disclose  PHI in response to a subpoena or court or administrative order.   Provider may also disclose PHI to defend any lawsuit and/or proceeding brought by Patient and/or Patient’s representative.

 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

 

1.  Psychotherapy Notes. Provider may keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires  Patient’s authorization unless set forth in Section IV.

 

2.  Marketing Purposes. Provider will not use or disclose  PHI for marketing purposes.

 

3.  Sale of PHI. Provider will not sell your PHI in the regular course of business.

 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose  PHI without the patient’s authorization for the following reasons:

 

1.  When disclosure is required by state or federal law, and the use or disclosure complies  with and is limited  to the relevant  requirements of such law.

 

2.  For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

 

3.  For health oversight activities, including but not limited to audits and investigations by the Secretary of Health and Human Services.

 

4.  For judicial and administrative proceedings, including responding to a subpoena, court or administrative order.

 

5.  For law enforcement purposes, including reporting crimes.

 

6.  To coroners or medical examiners, when such individuals are performing duties authorized by law.

 

7.  For research purposes, including studying and comparing the mental health of patients who received  one form of therapy versus those who received  another form of therapy for the same condition.

 

8.  For workers' compensation purposes. 

 

9.  Appointment reminders and health related benefits or services.  I may use and disclose  your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose  your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

10.  To respond to information requested by Patient’s health insurance carrier.

 

11.  For Provider to bill the Patient or Patient’s health insurance carrier for services rendered by Provider to Patient.

 

12.  For Provider to collect any amounts due from Patient.

 

13.  To protect grave bodily harm or death to Patient.

 

14.  For Provider’s use in training or supervising mental health practitioners to help them improve  their skills in group,    joint, family, or individual counseling or therapy.

 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:

 

1.  Provider may provide PHI to a patient’s family member, friend, or other person that You

indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

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VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

 

1.  The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask Provider not to use or disclose  certain PHI for treatment, payment, or health care operations purposes. Provider is not required to agree to your request.

 

2.  The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of PHI to health insurance carriers for payment or health care operations purposes if the PHI pertains  solely to a health care item or a health care service that you have paid for out-of-pocket in full.

 

3.  The Right to Choose How I Send PHI to You. You have the right to ask Provider to contact You in a specific way (for example, home or office phone) or to send mail to a different address, and Provider will agree to all reasonable requests.

 

4.  The Right to See and Get Copies of Your PHI. You have the right to get an electronic or paper copy of your medical record  and other information that Provider has about You. I will provide You with a copy of your record,  or a summary of it, if You agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable,  cost based fee for doing so.

 

5.  The Right to Get a List of the Disclosures I Have Made.  You have the right to request a list of instances in which Provider has disclosed your PHI for purposes  other than treatment, payment, or health care operations, or for which You provided me with an Authorization. Provider will respond  to your request for an accounting of disclosures within 60 days of receiving your request.  The list will include disclosures made in the last six years unless You request a shorter time. Provider will provide  the list to You at no charge, but if You make more than one request in the same year, Provider will charge you a reasonable cost based fee for each additional request.

 

6.  The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, You have the right to request that Provider correct the existing information or add the missing information. Provider may say “no” to your request,  but will tell you why in writing within 60 days of receiving your request.

 

7.  The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and You have the right to get a copy of this notice by e-mail.  And, even if You have agreed to receive this Notice via e-mail,  You also have the right to request a paper copy of it.

 

Acknowledgement  

 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. 

 

If you choose to participate in the services that require it, you will receive a copy of this information from your provider to sign off on.