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Notice of Privacy Practices

This notice is effective April 14, 2003.

This notice describes how your protected health (mental health) information (PHI) may be used and disclosed, and also how you can obtain access to your information. Please review the notice carefully.

Your health care (mental health) information is personal and private, and I am committed to protecting it. This notice tells you about the ways in which I may use and disclose your health care (mental health) information. Generally, I am required by law to ensure that health care (mental health) information that identifies you is kept private. I am required to give you this notice of my legal duties and privacy practices with respect to your health care information. I am required to follow the terms of the Federal Privacy Practices notice that is currently in effect.

Except for specific circumstances, federal and/or state law requires special protections for PHI related to mental health, alcohol and drug abuse, sexually transmitted disease, and HIV/AIDS. According to applicable law, I will not use or disclose this or other specially protected health care information without your written authorization.

If you are under 18, your parent or legal guardian is entitled to health care information about you, and is the one who would make decisions about who has access to your information. If you are an adult and you have a conservator, your conservator would make decisions about access to your PHI.

Your protected health information may be used for:

Treatment – Information obtained from you, will be recorded in your medical (mental health) record. This information is confidential and will not be released without your written permission. If you have insurance or other third party reimbursement, I may need to contact the appropriate agency so that they can help make known your eligibility for services, or about the services which would be most helpful for your. If you are self-referred, I will not release treatment information to anyone without your prior written authorization.

Payment – If an insurance company or other third party is paying for your treatment, I will need to release information to them so that I can be paid for my services. This will include basic information, such as your identifying information, mental health diagnosis, and the services that I provided to you.

Health Care Operations – I may use your medical (mental health) information for health care operations to make sure that the services and care provided to you are appropriate and of high quality.

I may share your health care (mental health) information with public agencies or other organizations in instances in which I am required or permitted by law to do so. For instance, in the event that I have reasonable suspicion of child abuse, elder/dependent adult abuse, or assess that you are at imminent risk of danger to yourself or someone else, your information may in some situations, be mandated by law to be reported.

Please be aware that, although I am required to inform you these possibilities, many of the types of disclosures listed below are rare, or have never occurred in my practice.

Health Oversight Activities – For activities authorized by law; for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights and privacy laws.

Public Health Activities – To prevent or control disease, injury or disability; to notify an individual who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to report births and deaths; to report the abuse or neglect of children, elders and dependent adults; to report reactions to medications or problems with products; to notify people of recalls of products they may be using.

Organ and Tissue Donation – To organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Research – For research that has been approved by an institutional review board that has reviewed the research proposal and established guidelines to ensure the privacy of your PHI.

To Avert a Serious Threat to Health or Safety – To prevent a serious threat to your health and safety or the health and safety of the public or another persona. Any disclosure, however, would only be to someone able to prevent the threat.

To a Correctional Institution – If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may release your PHI to the correctional institution or law enforcement official. The information released must be necessary for the institution to provide you with health care, protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

Military and Veterans – If you are a member of the armed forces, I may release PHI about you as required by military command authorities. I may also release PHI about foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities – to authorized federal officials for intelligence, counterintelligence, protections of the President or foreign heads of state and other national security activities authorized by law.

Government Programs Providing Public Benefits – To determine eligibility for or enrollment in a government funded health plan, such as Medicare or Medicaid.

Workers’ Compensation or Similar Programs – As authorized by law, relating to workers’ compensation programs.

Individuals Involved in your Care or Payment for your Care – Unless there is a specific written request from you the contrary, I may disclose your health care information to a friend or family member who is involved in your health care or payment for that care. In addition, I may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Appointment Reminders– I may use PHI to contact you as a reminder that you have an appointment with me.

Your Written Authorization Is Required

If I want to use or disclose your PHI for any reason not listed above, I must get your written authorization. If you give me your authorization, you may choose to take it back in writing and I will stop using or disclosing your PHI indicated in the authorization. However, please understand that I am unable to take back any disclosure I may have already made based on the authorization, and that I am required to retain my records of the care that I provided for you.

Your Protected Health Information Rights

With certain exceptions, you have the right to inspect and obtain a copy of the health care information that may be used to make decisions about your care. Usually, this includes health care (mental health) and billing records, but does not include information that is needed for civil, criminal or administrative actions or proceedings or psychotherapy notes. I may charge a fee for the costs of copying, mailing or other tasks or supplies associated with your request. Note that if I write a psychological report for a referring professional, it may not be appropriate or helpful for you to read the report yourself. This is because special professional language and terms will be used in the report, and you could misinterpret the information or find it disturbing. Legal and ethical mandates require me to take steps to prevent the harm that such misinterpretation might cause. Because of this, it is generally best

to request that my report be forwarded to your doctor, counselor, or other professional, so that this person can help to explain the information. If you would like a report for your records, I may write a summary of your record for you, for a nominal fee.

Right to Amend

If you feel that health care (mental health) information I have about you is incorrect or incomplete, you may ask me to amend the information. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask to amend information that:

  • Was not created by me;
  • Is not part of the Protected Health Information kept by or for me;
  • Is not part of the information which you would be permitted to inspect or copy; or
  • Is accurate and complete.

Right to an Accounting of Disclosures

You have he right to request a list of the disclosures I made of PHI about you, other than for my own uses for treatment, payment and health care operations, and with other exceptions pursuant to the law. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003.

Right to Request Restrictions

You have the right to request a restriction or limitation on the PHI I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI I disclose about you to someone who is involved in your care or the payment of your care, like a family member.

Right to Request Confidential Communication

You have the right to request that I communicate with you about your PHI in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice

You have the right to request a copy of this notice at any time. I reserve the right to change my information practices in accordance with applicable law and to make the new provisions effective for all PHI I maintain. Should my information use and disclosure practices change, I will provide you with a revised Notice of Privacy Practices upon request.

Questions or Complaints

If you have any questions about this notice or your privacy rights, please contact me at the address above. If you believe your privacy rights have been violated, you may file a complaint, in writing, with me or with the Secretary of the Department of Health and Human Services. To file a complaint with me, write to me at the address above. You will not be penalized in any way for filing a complaint.

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