THIS NOTICE DESCRIBES HOW MEDICAL/ PROTECTED HEALTH
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
By law, we are required to provide you with our notice of Privacy Practices. This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information. As a client, you have the following rights:
1. The right to inspect and copy your information
2. The right to request corrections to your information.
3. The right to request that your information be restricted.
4. The right to request confidential communications.
5. The right to a report of disclosures of your information.
6. The right to a copy of this notice.
We are required to protect the privacy of medical/ health information about you and of any information that can be identified with you. We want to assure you that your medical/protected health information is secure with us. This notice contains information about how we will ensure that your information remains private. Protected health information is contained in your treatment and billing records
maintained by this office. It contains demographic information and information that relates to your present, past or future physical and mental health and related healthcare services. This Notice applies to uses and disclosures that we may make of your protected
health information, whether created by us or received by us from another healthcare provide or other source.
OUR LEGAL DUTY TO PROTECT YOUR HEALTH INFORMATION:
Federal law requires us to: Maintain the privacy of your protected health information, whether the record is created in our office or received from another healthcare provider; Maintain the privacy of your protected health information regarding payment for
your healthcare; Give you this notice of our legal duties and privacy practices regarding your protected health information and explain when and why we use and disclose protected health information about you; Abide by the terms of this Notice, as currently in effect;
Notify you if we are unable to agree to a requested restriction on how your protected health information is used or disclosed;
Accommodate reasonable requests that you make to communicate health information by alternative means or at alternative locations; and Obtain your written permission to use or disclose your protected health information for reasons other than those listed below and permitted by law. We know that your protected health information is personal. We are committed to protecting your information. We document (in medical and financial records) the care and services that we provide to you to ensure that we provide you with good care and that
we follow all legal requirements. This Notice applies to those records and to all information you share during assessment and treatment .
Changes to this Notice: We reserve the right to change the terms of this Notice of Privacy Practices and to make the new provisions effective for all protected health information we already have about you as well as any protected health information we create or receive in the future. If we make any changes, we will post notice of revision with effective date in our office and will make copies of the revised notice available to you upon request.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU:
For treatment: We may use and disclose your protected health information to provide you with behavioral health treatment and/or services and to coordinate or manage your healthcare and related services. We may use and disclose your protected health information to doctors, nurses, counselors, social workers and support staff within our organization and with other healthcare providers involved
in your care. We may disclose information to people outside of our office who may be directly involved in your care; such as guardians, family members, clergy or others who participate in your care. All such information is recorded in your medical record where healthcare providers also record actions taken by them in the course of your treatment and note your reactions. We may also disclose your
protected health information to providers or facilities who may be involved in your treatment after you leave our care.
Examples of how we may disclose information for treatment may include sharing assessment and treatment information about you with your primary care physician, your psychiatrist, etc.
For payment: We may use and disclose your protected health information so that we can bill and receive payment for the treatment and services you receive from us. For billing and payment purposes, we may disclose your protected health information to an insurance company, a managed care company or any other third party payer. The information on the bill may contain information that identifies
diagnoses and treatment procedures. We may inform an insurance company about treatment that we intend to provide you so that we can obtain the appropriate approvals and/or confirm coverage for your treatment.
Examples of how we will disclose information for payment include:
a. We may contact your health plan to confirm your coverage,
b. We may contact your health plan for pre-certification of a service,
c. We may share information with agents of health plans (third party
administrators) who are involved in the payment of a claim,
For healthcare operations: We may use and disclose your protected health information in performing business activities that we call “healthcare operations”. This includes internal operations, such as for general administrative activities and to monitor the quality of care you receive at our office. This type of use may be necessary for us to run our organization and to be sure that our clients are receiving quality care.
Examples of how we may use and disclose information as it relates to healthcare operations may include one or more of the following:
a. We may use or disclose your protected health information to review and improve the quality of care that you receive;
b. We may use or disclose your protected health information to doctors, nurses, counselors, social workers or other staff for education and training purposes;
c. We may use or disclose your protected health information for planning for services, such as when we access certain services that we may want to offer in the future;
d. We ay use or disclose your protected health information to our lawyers, consultants, accountants, and business associates;
e. We may combine information about several clients to determine if we should offer new services;
f. We may combine information about several clients to determine if new treatments are effective;
g. We may use protected health information to identify groups of clients who have similar problems to give them information about treatment alternatives, programs, or other new procedures;
h. We may use or disclose your protected health information to train students, residents, other healthcare providers or non-healthcare providers (such as billing personnel);
i. We may use or disclose protected health information to organizations that access the quality of care we provide to our clients (such as government agencies or accrediting bodies);
j. We may use and disclose protected health information to organizations that evaluate, certify, or license healthcare providers, staff or facilities in a particular specialty;
k. We may use and disclose protected health information to assist others who may be reviewing our activities such as accountants, lawyers, consultants, risk managers, and others who assist us in complying with state and federal laws;
l. We may use and disclose protected health information in the process of reviewing for healthcare fraud and abuse detection and compliance;
m. We may use and disclose protected health information when we develop internal protocols;
n. We may use and disclose your protected health information when we attempt to contact you by leaving messages on answering machines, asking for you by name on the telephone, call you by name when you are in our office building, etc. We will take reasonable steps to limit incidental disclosures.
OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR
Under the Health Insurance Portability and Accountability Act Privacy Regulations, we may use and disclose your protected health information in which you do not have to give authorization or otherwise have an opportunity to agree or object. “Use” refers to our
internal utilization of your protected health information. Specifically, “use” under the privacy regulation means: “….with respect to individually identifiable health information, the sharing, employment, application, utilization; examination, or analysis of such information within an entity that maintains such information.” Disclosure refers to
the provision of information by us to parties outside of our organization. Specifically, disclosure means: “…the release, transfer, provision of access to or divulging in any other manner, of information outside of the entity holding that information.” We may
make the following uses and disclosures of your protected health information without obtaining a written authorization from you in situations such as: Those Required by Law: We may disclose your protected health information when required to do so by law. For example, when federal, state or local law or administrative proceeding requires that we disclose information about you. Public Health Risk: We may disclose your protected health information for
public health activities. For example, we may disclose protected health
information about you if you have been exposed to a communicable disease or may otherwise be at risk of spreading a disease. Other examples may include reports about injuries or disability and reports of child abuse and neglect. Our Facility Directory: Unless you object, we may use and disclose certain limited information about you while you are in our office building. This information may include your name and your location within our building, but will not include specific medical information about you. We may disclose directory information to people who ask for you by name Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose protected health information about you to a family member, close personal friend, caregiver, neighbor or other person(s) you identify, including clergy, who are involved in your care. These disclosures are
limited to information relevant to the person’s involvement in your care or payment for your care. Disaster Relief: Unless you object, we may disclose protected health information about you to a public or private agency (like the American Red Cross) for disaster relief purposes. Even if you object, we may still share information about you, if
necessary for the emergency circumstances. Reporting Victims of Abuse, Neglect or Domestic Violence: When required or
authorized by law, we may use and disclose your protected health information to notify a government authority of abuse, neglect or domestic violence. Health Oversight Activities: When authorized by law, we may disclose your protected health information to a health oversight agency. A health oversight agency is a state or federal agency that oversees the healthcare system. Some of the activities may include, for example, audits, investigations, inspections and licensure.
Judicial and Administrative Proceedings: We may disclose your protected health information in response to a lawsuit, dispute, court or administrative order. We may also disclose protected health information in response to a subpoena, discovery request, or other lawful process by another party involved in the action.
We will make reasonable effort to inform you about the request.
Law Enforcement: We may disclose your protected health information for certain law enforcement purposes, including, but not limited to:
a. Reporting emergencies or suspicious deaths;
b. Complying with a court order, subpoena, or other legal process;
c. Identifying or locating a suspect or missing person, material witness or fugitive;
d. Answering certain requests for information concerning crimes, about the victims of crimes;
e. Reporting and/or answering questions about a death we believe may be the result of a crime;
f. Reporting criminal conduct that took place on our premises; and
g. In emergency situations, to report a crime, the location of a crime or
victim or the identity, description and/or location of a person involved
in the crime.
Research: In some situations, your protected health information may be used for research purposes if an institutional board has approved the research. The institutional board must have established procedures to ensure that your protected health information remains confidential.
To Avert A Serious Threat To Health Or Safety: We may use or disclose your protected health information to someone able to lessen or prevent the threatened harm when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person.
Military and Veterans: If you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities. We may also release information about you if you are a member of a foreign military as required by the appropriate foreign military authority.
National Security and Intelligence Activities: We may disclose protected health information to authorized federal officials conducting national security, counterintelligence, and intelligence activities authorized by law. Protective Services for the President and Others: We may disclose your protected health information to authorized federal officials as needed to provide protection to the President of the United States, other persons or foreign heads of states or to conduct certain special investigations.
Inmates/ Law Enforcement Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your protected health information to the correctional institution or official if necessary for the following reasons:
a. To insure that the correctional institution will provide you with
b. To protect your own health and safety;
c. To protect the health and safety of others; and/or
d. For the safety and security of the correctional institution.
Workers’ Compensation: We may use or disclose your protected health
information to comply with laws and regulations relating to workers’
compensation or similar programs established by law that provide benefits for work-related injuries and/or illness.
Appointment Reminders or Rescheduling: We may use or disclose protected health information to contact you about appointments with our office.
Treatment Alternatives and Health-Related Benefits and Services: We may use or disclose your protected health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you. This may include telling you about a. treatments; b. services; c. products; d. other healthcare providers; e. special programs; f. nutritional services. Business Associates: We may disclose your protected health information to our
business associates under a Business Associate Agreement. Some of these business associates may include, for example: a. Receptionist and Support Services; b. Answering Service; c. Accounting Services; d. Attorney/ Legal Services.
ANY OTHER USE OR DISCLOSURE OF YOUR PROTECTED HEALTH
INFORMATION REQUIRES YOUR WRITTEN AUTHORIZATION
Under any circumstances other than those listed above, we will request that you provide us with a written authorization before we use and disclose your protected health information to anyone. If you sign an authorization allowing us to disclose protected health information about you in a specific situation, you can later revoke (cancel) your
authorization in writing. If you cancel your authorization in writing, we will not disclose your protected health information about you after we receive your cancellation, except for disclosures which were already being processed or made before we received your
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding protected health information that we maintain about you:
The Right to Access Your Personal Protected Health Information: Upon
written request, you have the right to inspect and obtain a copy of your medical/protected health information except under limited circumstances. We may charge you a reasonable fee for the costs of copying, mailing and/or supplies related to this request. We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to your medical/ protected health information, in some cases you will have the right to request a review of this denial. A licensed healthcare professional designated by us and who did not participate in the original decision to deny access will perform this review.
The Right to Request Restrictions: You have the right to request a restriction on the way we use or disclose your protected health information for treatment, payment or healthcare operations. You can request that we limit the information we disclose about you to those individuals involved in your care or the payment for your services. You should request in writing what information you want restricted, to whom you want the restrictions to apply, and whether you want to
limit our use, disclosure, or both. We are not required to agree to such a
restriction, but if we do so agree, we will honor that restriction except in the event of an emergency and then will only disclose the restricted information necessary for your emergency care and treatment.
The Right to Request Confidential Communication: You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number or a specific address or by a specific method. We will accommodate all reasonable requests, but may deny that request if you are
unable to provide us with appropriate methods of contacting you.
The Right to Request an Amendment: You have a right to request that we make amendments or modify your clinical, billing or other protected health information for as long as the information is kept by us. Your request must be in writing and must explain your reasons for the requested amendment. We may deny your request for amendment if the information:
a. was not created by us;
b. is not part of the records maintained by us;
c. in our opinion, is accurate and complete;
d. is information to which you do not have the right of access.
If we deny your request for amendment, we will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your letter of disagreement will be attached to your medical record.
The Right to an Accounting of Disclosures: You have the right to request an accounting/ report of certain disclosures of your protected health information.
You may ask for disclosures made up to six years prior to your request. This is a listing made by us or by others on our behalf. We are not required to include disclosures:
a. made for treatment;
b. made for billing or collection of payment for your treatment;
c. made directly to you, that your authorized, or to those which were
made to individuals involved in your care;
d. allowed by law when the use or disclosure relates to certain
government functions or in other government custodial situations;
e. made in the process of our healthcare operations.
You must submit your request for an accounting of disclosures in writing and state the time period for which you would like an accounting.
If you believe that your privacy rights have been violated, you may file a complaint in writing with us or with the government.
To file a complaint with the government, you may contact:
Office of Civil Rights, U.S. Department of Health and Human Services
200 Independence Ave., S.W. Room 509F
Washington, D.C. 20201
To file a complaint with us, you should contact
Dan Maust, MEd/LPCC-S
1375 US Highway 42 SE, Ste C
London, OH 43140
You will not be retaliated against for filing a complain.