Notice of Privacy Practices

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

EFFECTIVE DATE OF THIS NOTICE: April 1, 2021

I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to health information.

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

  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request and in our office.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I may use and disclose PHI for treatment. The examples included with each category do not list every type of use or disclosure that may fall within that category

For Treatment: We may use your PHI to provide you treatment or services. For example, information obtained by a therapist will be recorded in your record and used to determine your plan of care. We may also, with your authorization, disclose your medical information to another healthcare provider who is involved in your care.

Payment: We may use your PHI to secure payment for your treatment or services. For example, the information on a bill sent to you, your insurance company may include information that identifies you, as well as the treatment provided to you. We may also tell your health plan about the treatment you are going to receive to determine whether your plan will cover it.

Special Notices: We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means such as email or text unless you tell us in writing that you would prefer not to receive them.

Agency Operations: We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, insurance review, legal services, auditing functions, and patient safety activities.

III. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your 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 audits and investigations.

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain Authorization from you before doing so.

  5. For law enforcement purposes, including reporting crimes occurring on my premises.

  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. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

  9. For workers' compensation purposes. Although my preference is to obtain Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

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

  1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or another 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.

V. 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 me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may deny your request if I believe it would affect your health care.

  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 your PHI to health plans 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 me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have 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 I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with Authorization.

  6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your health information or that a piece of important information is missing, you have a right to ask that we correct or update your information. You may request an amendment for as long as we maintain your health information. In certain cases, we may deny your request for amendment, and if this occurs, you will be notified of the reasons that your request was denied. You have the right to file a statement of disagreement with the decision, and we may prepare a response to your statement. You may also ask that we include a copy of your request and our denial with all future disclosures of that specific health information.

  7. The Right to Get a Paper or Electronic Copy of this Notice. You may request a paper copy of this Notice at any time even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy of the Notice.

  8. The Right to Withdraw your consent to use or disclose PHI, except to the extent that action has already been taken. You may withdraw or “revoke” consent in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the consent.