Notice of Privacy Practices 

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

Our Duty to Safeguard Your Protected Health Information. 

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (PHI).  As part of our normal business operations, we encounter your PHI as a result of your treatment, our payment and other related health care operations.  We also receive your PHI via the application and enrollment process, from healthcare providers and health plans, and by a variety of other activities.  Accordingly, we are required to extend certain protections to you and your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use and/or disclose your PHI.  Except in specified circumstances, we are required to use and/or disclose only that minimum amount of your PHI necessary to accomplish the purpose of our use and/or disclosure. 

We are required to follow the privacy practices described in this Notice, although we reserve the right to change our privacy practices and the terms of this Notice at any time.  In the event that we change our privacy practices, we will post our updated Notice in the office.  We will also provide more detailed information at your request regarding the topics addressed in our Notice.  You may request a hard copy of our Notice by submitting a written request to the above address. 

How We May Use and Disclose Your Protected Health Information. 

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its HIPAA Privacy Rule (Rule), we may use and/or disclose your PHI for a variety of reasons.  Generally, we are permitted to use and/or disclose your PHI for the purposes of treatment, the payment for services you receive, and for our normal health care operations.  For most other uses and/or disclosures of your PHI, you will be asked to grant your permission via a signed Authorization.  However, the Rule provides that we are permitted to make certain other specified uses and/or disclosures of your PHI without your Authorization.  The following information offers more descriptive examples of our potential use and/or disclosure of your PHI. 

1. Uses and/or disclosures related to your treatment, the payment for services you receive, or our health care operations (TPO):

1. For treatment (T): We may use and/or disclose your PHI with psychologists, psychiatrists, physicians, nurses, and other health care personnel involved in providing health care services to you.  For example, your PHI may be shared with your primary care physician, medical specialists, members of your treatment team, mental health service providers to whom you are referred, and other similarly situated health care personnel involved in your treatment.

2. For payment (P): We may use and/or disclose your PHI for billing and collection activities and related data processing; for actions by a health plan or an insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and the provision of benefits under its health plan insurance agreement; to make determinations of eligibility or coverage, adjudication or the subrogation of health benefit claims; for medical necessity and appropriateness of care reviews, utilization review activities, and related payment activities so that individuals involved in delivering health services to you may be properly compensated for the services they have provided.
3. For health care operations (O): We may use and/or disclose your PHI in the course of operating the various business functions of our office.  For example, we may use and/or disclose your PHI to evaluate the quality mental health services provided to you; develop clinical guidelines, contact you with information about treatment alternatives or communications in connection with your case management or care coordination; to review the qualifications and training of health care professionals; for medical review, legal services, and auditing functions; and for general administrative activities such as customer service and data analysis.
4. Appointment reminders: Unless you request that we contact you by other means, the Rule permits us to contact you regarding appointment reminders and other similar materials to you.

2. Uses and/or disclosures requiring your Authorization:  Generally our use and/or disclosure of your PHI for any purpose that falls outside of the definitions of treatment, payment and health care operations identified above will require your signed Authorization.  The Rule does not grant us permission for certain specified uses and/or disclosures of your PHI that fall outside of the treatment, payment and health care operations definitions as itemized below.  However, for all other uses and/or disclosures of your PHI by any other person or entity, you retain the power to grant your permission via your signed Authorization.  Additionally, if you grant your permission for such use and/or disclosure of your PHI, you retain the right to revoke your Authorization at any time except to the extent that we have already undertaken an action in reliance upon your Authorization.

3. Use and/or disclosure not requiring your Authorization:  The Rule provides that we may use and/or disclose your PHI without your Authorization in the following circumstances:

1. When required by law:  We may use and/or disclose your PHI when existing law requires that we report information including each of the following areas:

2. Reporting abuse, neglect or domestic violence: We may use and or disclose your PHI of suspected victims of abuse, neglect, or domestic violence including reporting the information to social service or protective services agencies.
3. Public health activities:  We may use and/or disclose your PHI to prevent or control the spread of disease or other injury, public health surveillance or investigations, reporting adverse events with respect to food, dietary supplements, product defects and other related problems to the Food and Drug Administration, medical surveillance of the workplace or to evaluate whether or not you have a work-related illness or injury, in order to comply with Federal or state law.
4. Health oversight activities:  We may use and/or disclose your PHI to designated activities and functions including audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions. Or other activities necessary for appropriate oversight of government benefit programs.
5. Judicial and administrative proceedings:  We may use and/or disclose your PHI in response to an order of a court or administrative tribunal, a warrant, subpoena, discovery request, or other lawful process.
6. Law enforcement activities:  We may use and/or disclose your PHI for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person, or reporting crimes in emergencies, or reporting a death.
7. Relating to decedents:  We may use and/or disclose the PHI of an individual’s death to coroners, medical examiners and funeral directions.
8. For research purposes:  In certain circumstances, and under the supervision of an Internal Review Board, we may disclose your PHI to assist in medical/psychiatric research.
9. To avert a serious threat to health or safety:  We may use and/or disclose your PHI in order to avert a serious threat to health or safety.
10. For specific government functions:  We may use and/or disclose the PHI of military personnel and veterans in certain situations.  Similarly, we may disclose the PHI of inmates to correctional facilities in certain situations.  We may also disclose your PHI to governmental programs responsible for providing public health benefits, and for workers’ compensation.  Additionally, we may disclose your PHI, if required, for national security reasons.

4. Uses and/or disclosures requiring you to have an opportunity to object:  We may disclose your PHI in the following circumstances if we inform you about the disclosure in advance and you do not object.  However, if there is an emergency situation and you cannot be given an opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests.  You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

1. To families, friends or others involved in your care.  We may share your PHI with those people directly involved in your care, or payment for your care.  We may also share your PHI with these people to notify them about your location, general condition, or death. 
    
   

Your Rights Regarding Your Protected Health Information (PHI). 

      The HIPAA Privacy Rule grants you each of the following individual rights: 

1. The right to view and obtain copies of Your PHI.  In most cases, you have the right to look at or obtain copies of your PHI that I have, but you must make the request in writing.  If I don’t have your PHI but I know who does, I will tell you how to get it.  I will respond to you but in certain situations, I may deny your request.  If I do, I will explain your right to have my denial reviewed. 
   1. If patient is a minor.  If you are a parent that is the legal representative of a minor, please note that the records of a minor may not be available to you.  For example, if your therapist determines, in good faith, that access to the patient records requested would have a detrimental effect on the therapist’s professional relationship with the minor patient or on the minor’s physical safety or psychological well-being or if the records pertain to health care services for which the minor can lawfully give consent the records may not be available to the minor’s parents or legal representative.
2. The right to request limits on uses and disclosures of your PHI.  You have the right to ask that I limit how I use and disclose your PHI.  While I will consider your request, I am not legally bound to agree.  If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations.  You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.
3. The right to choose how I send your PHI to you.  It is your right to ask that your PHI be sent to you at an alternate address or by an alternate method, e.g., e-mail.  I am obliged to agree to your request providing that I can give you the PHI in the format you requested, without undue inconvenience.
4. The right to get a list of the disclosures I have made.  You are entitled to a list of disclosures of your PHI that I have made.  The list will not include uses or disclosures to which you have already consented, e.g., those for treatment, payment, or health care operations, sent directly to you or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 14, 2003.  After April 14, 2003, disclosure records will be held for six years.  I will respond to your request for an accounting of disclosures within 60 days of receiving your request.  The list I provide to you will include disclosures made in the previous six years (the first six-year period being 2003-2009) unless you indicate a shorter period.  The list will include the date of the disclosure, to whom PHI was disclosed (including their address if known), a description of the information disclosed, and the reason for the disclosure.  I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.
5. The right to amend your PHI.  If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information.  Your request and the reason for the request must be made in writing.  You will receive a response within 60 days of my receipt of your request.  I may deny your request in writing if I find that: the PHI is (a) correct and complete,  (b) forbidden to be disclosed,  (c) not part of my records, or (d) written by someone other than me.  My denial must be in writing and must state the reasons for the denial.  It must also explain your right to file a written statement objecting to the denial.  If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI.  If I approve your request, I will make the change(s) to your PHI.  Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.

      How to Complain about our Privacy Practices. 

If you believe that we may have violated your individual privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint by submitting a written complaint to __________________________________________________  Your written complaint must name the person or entity that is the subject of your complaint and describe the acts and/or omissions you believe to be in violation of the Rule or the provisions outlined in our Notice of Privacy Practices.  If you prefer, you may file your written complaint with the Secretary of the U.S. Department of Health and Human Services (Secretary) at 200 Independence Avenue S.W., Washington, D.C., 20201.  However, any complaint you file must be received by us, or filed with the Secretary, within 180 days of when you knew, or should have known, the act or omission occurred.  We will take no retaliatory action against you if you make such complaints.