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 IT CAREFULLY.
We collect and create personal information about you and your health. State and federal law protects your privacy by limiting me in how we may use and disclose such information. Protected health information (“PHI”) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care.
Your Rights Regarding Your PHI. The following are rights you have regarding PHI that I maintain about you:
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and receive a copy of the PHI that I maintain. I may charge a reasonable, cost-based fee for the copying process. As to your PHI that I maintain in electronic form and format, you may request a copy to which you are otherwise entitled in that electronic form and format if it is readily producible, but if not, then in any readable form and format as we may agree (e.g., PDF). Your copy request may also include transmittal directions to a third party.
- Right to Amend. If you feel the PHI I have about you is incorrect or incomplete, you may ask me in writing to amend the information although I am not required to agree to the amendment. You may write a statement of disagreement if your request is denied. The statement will be maintained as part of your PHI and will be included with any disclosure.
- Right to an Accounting of Disclosures. I am required to create and maintain a prescribed accounting of certain disclosures I may have made of your PHI. You have the right to request a copy of such an accounting.
- Right to Request Restrictions. You have the right to request in writing a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am generally not required to agree to such a request. If I have been paid in full for all of the services covered by such a request, then I will honor a request to restrict disclosure to your insurance.
- Right to Request Confidential Communication. You have the right to request that I communicate with you in a certain way or at a certain location. I will accommodate reasonable requests and will not ask why you are making the request.
- Right to a Copy of this Notice. You have the right to obtain a paper copy of this notice upon request.
- Right of Complaint. You have the right to file a complaint in writing with me or with the Secretary of Health and Human Services if you believe I have violated your privacy rights. I will not retaliate against you for filing a complaint.
My Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
Treatment. I may use your PHI for the purpose of providing you with health care treatment, including management, coordination and continuity of your care with other of your current providers.
Payment. I may use your PHI in connection with billing statements I send you. I may use your PHI for the purpose of tracking charges and credits to your account. Unless you have requested and I have specifically agreed to restrict disclosure of your PHI to your health plan, I may disclose your PHI to third party payers to obtain information concerning benefit eligibility, coverage, and remaining availability as well as to submit claims for payment.
Health Care Operations. I may use and disclose your PHI for the health care operations of my professional practice in support of the functions of treatment and payment. Such disclosures would be to Business Associates for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist me in my delivery of your health care.
Other Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object
Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples are public health reports, abuse and neglect reports, law enforcement reports, and reports to coroners and medical examiners in connection with investigation of deaths. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Health Oversight. I may disclose your PHI to a health oversight agency for activities authorized by law, such as my professional licensure. Oversight agencies also include government agencies and organizations that audit their provision of financial assistance to me, such as third-party payers.
Threat to Health or Safety. I may disclose your PHI when necessary to minimize an imminent danger to the health or safety of you or any other individual.
Business Associates. I may disclose your PHI to the extent minimally necessary to Business Associates that are contracted by me to perform health care operations or payment activities on my behalf, which may involve their collection, use, or disclosure of your PHI. To safeguard the privacy of your PHI, such contracts are regulated by the Department of Health and Human Services and must contain provisions designed to limit the use and re-disclosure of your PHI, to require compliance by the Business Associate with your individual rights, to subject the Business Associate to specified security obligations, and to require the Business Associate to require such obligations of a subcontractor.
Compulsory Process. I will disclose your PHI if a court issues an appropriate order. I will also disclose your PHI if (1) you and I have each been notified in writing at least fourteen days in advance of a subpoena or other legal demand, identifying the PHI sought, and the date by which a protective order must be obtained to avoid my compliance, (2) no qualified judicial or administrative protective order has been obtained, (3) I have received satisfactory assurances that you received notice of your right to seek a protective order, and (4) the time for your doing so has elapsed.
Uses and Disclosures Requiring Your Opportunity to Agree or Object
Prior Providers. I may disclose your PHI to your prior health care providers, unless I have given you the opportunity to agree or object, and you have objected in writing.
Close Personal Relationships. In accordance with good professional practice, I may disclose your PHI to your person(s) who are close to you that are involved with your care, unless I have given you the opportunity to agree or object, and you have objected. When you are not present or in situations of your incapacity or in an emergency, and where disclosure, in my clinical judgment would be in your best interests, I will disclose your PHI as minimally necessary.
Disaster Relief Purposes. In situations of your absence, incapacity or emergency and in accordance with good professional practice, I may disclose your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, which are directly relevant to your identification and care.
Uses and Disclosures of PHI with Your Written Authorization
I will make other uses and disclosures of your PHI only with your written authorization. One example is my psychotherapy notes from our sessions (unless I am otherwise required by law). Unless I have taken a substantial action in reliance on the authorization such as providing you with health care services for which I must submit subsequent claim(s) for payment, you may revoke an authorization in writing at any time.
Certain Uses and Disclosures of PHI I do not make
I do not engage in academic or commercial research involving patient PHI. I do not engage in marketing activities using patient PHI. I do not engage in the sale of patient PHI. I do no fundraising using patient PHI. I do not maintain directory information for public disclosure. I do not receive compensation for recommending any health care product or service.
This Notice of Privacy Practices informs you how I may use and disclose your PHI and your rights regarding your PHI. I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to your PHI, and to notify you following a breach of unsecured PHI related to you. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by providing you a copy upon your request or by providing you a copy at your next appointment.
I am my own Privacy/Security Official. So, if you have any questions about this Notice of Privacy Practices or complaints about how your PHI has been utilized, please contact me. My contact information is: _Lea Sullivan (253) 363-0337, email@example.com. I will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.
The effective date of this Notice is September 23, 2013