HIPAA PRIVACY STATEMENT

Last modified: January 01, 2023

NOTICE OF HEALTH INFORMATION 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

I. OUR OBLIGATIONS TO YOU

This Notice of Privacy Practices (“Notice”) tells you about the ways that (“Facility”) may use and disclose your Protected Health Information, also known as “PHI.” We also describe your rights and certain duties we have concerning the use and disclosure of PHI. Your PHI includes information that identifies you and the health care you receive. We may use or disclose your PHI to provide treatment to you, to seek payment for the treatment provided, to support our health care operations, and for other purposes that are permitted or required by law.

We are required by the Federal Privacy Rules to:

• Maintain the privacy of your PHI.
• Provide you with this Notice.
• Let you know about our legal duties and privacy practices about the PHI we collect and maintain about you.
• Agree to the terms of this Notice, subject to the following: We reserve the right to change our PHI practices and the terms of this Notice. If our PHI practices change, we will post and/or provide a revised Notice. We will not use or disclose your PHI without your consent or permission, except as described in this Notice.

II. WAYS WE MAY USE AND DISCLOSE INFORMATION:

Listed below are the ways that we use and disclose PHI.  For each use or disclosure, we will explain what we mean and give some examples. Please note that not every type of use or disclosure is listed in this Notice, but all of the ways we can use and disclose information fall within one of these areas.

For TREATMENT. Treatment means the provision, coordination, or management of your health care and related services by us and other health care providers involved in your care. It includes the coordination or management of health care by us with a third party, consultation between our practice and other health care providers relating to your care, or our practice’s referral of you to another health care provider or facility.

For PAYMENT. Payment means our activities to obtain reimbursement for the health care treatment provided to you, including billing, claims management, and collection activities. Payment also may include your insurance company’s work to determine eligibility, for claims processing, to assess medical necessity, and for utilization review.  We may use and disclose health information about you to obtain payment for our services.

• For example, prior to providing treatment, we may use your PHI to confirm that your health insurer will pay for the treatment. 

For HEALTH CARE OPERATIONS. Health care operations refer to our business activities that are necessary to run our facility and to make sure clients receive quality care. These activities include, but are not limited to, quality assessment and improvement activities, including outcome evaluations and development of clinical guidelines, client safety activities, activities to improve health or reduce health care costs, protocol development, and case management and care coordination.

Health care operations also include peer review of health care professionals; medical review, legal services and auditing functions; business planning and development; and business management and general administrative activities.

• For example, we may use your PHI to review the treatment by our health care providers; 
• We may also combine health information about many clients to decide what other services we should offer, what services are not needed, and whether certain new treatments are effective; 
• We may combine health information we have with health information from other facilities to compare how we are doing and see where we can make changes to improve the care and services we offer. We may remove information that identifies you from this set of health information so that others may use it to study health care and health care delivery without learning specific clients’ information.

To PERSONS INVOLVED IN YOUR CARE OR INVOLVED IN PAYMENT FOR YOUR CARE, AND NOTIFICATION. We may disclose PHI about you to a friend or family member who is legally involved in your care.

For APPOINTMENTS AND SERVICES. We may use or disclose your PHI to notify or remind you of an appointment. We may call your home or business, leave a message for you, or mail a post-card.

To BUSINESS ASSOCIATES. We may disclose PHI to other persons and companies who perform services related to our treatment, payment or health care operations for you, such as billing or transcription services. These third-parties are our “Business Associates,” and we require them to appropriately safeguard your information.

III. USES AND DISCLOSURES WITH YOUR WRITTEN AUTHORIZATION.

Except as otherwise described in this Notice, we may not use or disclose PHI without your written authorization, which you may revoke.

You may request that we use or disclose all or part of your PHI. Use and disclosure may be authorized to specified individuals or other recipients for a defined purpose over a particular timeframe.

While most authorizations must be in writing, in certain circumstances, we will accept oral authorizations to the extent permitted by state law. The minimum necessary amount of your PHI will be disclosed to comply with your authorization.

You may revoke your authorization at any time, but only regarding future uses or disclosures and only to the extent we have not already used or disclosed your PHI in reliance on your authorization. If your authorization was provided as a condition of your obtaining insurance coverage, then if the insurer has a right to contest a claim, the revocation may be ineffective. We may also accept oral revocations and certain electronic revocations of authorizations, but we request that you follow this with a revocation in writing.

Authorizations may be required to disclose certain types of PHI:

For MARKETING.We will not disclose your PHI for any marketing purposes without your written authorization except if the communication is in the form of a face-to-face communication made to you personally, or a promotional gift of nominal value. Marketing does not include sending you information related to your individual treatment, case management, care coordination or directing you to alternative treatment therapies, healthcare providers or settings of care. If the marketing is to result in financial remuneration by a third-party we will state this on the authorization.

IV. USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR WRITTEN AUTHORIZATION

There are particular situations in which your PHI can be used or disclosed without your authorization, including but not limited to the following situations:

As REQUIRED BY LAW. We will use and disclose information about you when required to do so by federal, state, or local law.

In EMERGENCIES. If you are unable to provide an authorization or are otherwise incapacitated, and require emergency medical treatment, we will use and disclose your PHI for you to receive health care treatment. We will attempt to obtain your authorization, as soon as practical.

To prevent a serious threat to health or safety. We may disclose your PHI in a manner that is consistent with applicable laws and professional ethics, to prevent or lessen a serious and imminent threat to the health or safety of any person or the public, and disclose PHI to someone in a position to prevent or lessen the threat, including to the target of the threat. Disclosure may also be made to law enforcement officials to identify or apprehend a person involved in a violent crime involving serious physical harm to a person, or if escape from a correctional institution or lawful custody is believed to have occurred.

To REPORT ADULT ABUSE OR NEGLECT; DOMESTIC VIOLENCE; RISK OF HARM. We may disclose your PHI in connection with reports that we may be required or authorized to make regarding abuse, neglect, or domestic violence. Such disclosure will be limited to the extent required by law, or if disclosure is authorized but not required, will be made as necessary to prevent serious harm to you or others. We may also make such disclosure if you agree. To the extent that the disclosure will be made, we will promptly inform you or your Personal Representative, unless we believe informing you or your Personal Representative would place you at risk of serious harm. 

For Health Oversight Activities. We may disclose health information to a health oversight agency for actions required by law. Actions may include, for example, audits, investigations, inspections, and licensure.  These actions are needed for the government to monitor the healthcare system, programs, and compliance with civil rights laws.

In Judicial or administrative Proceedings. If you are involved in a lawsuit or dispute, we may disclose PHI about you in response to a court order.  We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if a court order has been obtained to protect the information requested.

To Law Enforcement. We may disclose health information if asked to do so by a law enforcement official:

• In response to a court order, warrant, summons;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of a crime;
• About a crime conducted at or on our premises; and
• In an emergency, to report a crime; the location of a crime or victims, or the identity, description or location of the person who committed the crime.

For PUBLIC HEALTH RISKS. We may disclose health information about you for public health reasons.  They include the following:

• To prevent or control disease, injury, or disability;
• To notify a state agency if we believe a client has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.

To Military AND VETERANS.  If you are a member of the armed forces, we may disclose health information about you as required by the military. We may also disclose health information about foreign military staff to the appropriate foreign military agency.

For National Security, Intelligence Activities. We may disclose health information about you to federal officials such as the FBI or CIA or any other national security activities authorized by law.

For PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS.  We may disclose health information about you to federal officials so they may protect the President, other persons, or foreign heads of state or conduct special investigations.

To Correctional FACILITIES.  If you are an inmate of a state or local prison or under the custody of a law enforcement official, we may disclose health information about you to the facility or law enforcement official. This disclosure would be necessary (1) to provide you with health care; (2) to protect your health and safety; or (3) for the health, safety, and security of the facility, including the other inmates, law enforcement, and other personnel.

V. RIGHTS THAT YOU HAVE REGARDING YOUR HEALTH INFORMATION:

To obtain a Copy of this Notice, you may request a paper copy of this Notice or view it electronically from our website at .

To Request a Restriction on Certain Uses and Disclosures. You have the right to request a limit on the health information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request, except we are required to agree to your request to not provide your insurance carrier with your health information if the PHI pertains solely to a health care item or service for which you have paid in full. If we do agree with your request for restriction, we will comply with your request unless the information is needed to provide you with emergency treatment or the restriction is terminated. To request restrictions, you must make your request in writing to the Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.

To Inspect and Request a Copy of Your Health Record. With limited exceptions, you have the right to inspect and copy health information that may be used to make decisions about your care. This includes health and billing records.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. The request must specify the records or types of records you desire and whether you would like access or copies. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, other supplies needed to support your request, including preparation of a summary of PHI. We also reserve the right to supervise your review of our records.

We may deny your request to inspect and copy in certain very limited circumstances. In these circumstances, we will allow you to designate in writing another person to inspect and copy your medical record. If you are denied access to a non-medical record, you may appeal that denial by submitting your appeal in writing to the Privacy Officer. We will choose another licensed health care professional to review your request and the denial. This person will be different from the person who denied your initial request. We will comply with the decision of the reviewing person.

To Request an Amendment to Your Health Record. If you feel that health information we have about you is incorrect or incomplete, you may ask us to change (amend) the information. You have the right to request a change for as long as the information is kept by or for us.

To request a change, your request must be made in writing and should be sent to the Privacy Officer. The request must specify the exact nature of the desired amendment and provide all the reasons that support your request.

If you request a change to your treatment record, we will include your written changes as part of the medical record. We may add to the record a response, and will provide you a copy of our response.

If you request a change to a non-treatment record, we may deny your request if it is not in writing or does not include a reason to support the request. We may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for the us;
• Is not part of the information which you would be allowed to inspect and copy; or
• Is accurate and complete.

If your request for an amendment is denied, you may submit a written statement of disagreement that provides the basis for your disagreement and we may prepare a written rebuttal to your statement of disagreement.

To Request an Accounting of Disclosures of Your Protected Health Information. You have the right to request an “accounting of disclosures.” This is a list of disclosures we made of medical information about you that are not for treatment, payment, or operations and have not already been authorized by you.

To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period and may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Notification of Breach of Unsecured Protected Health Information. We are required to notify affected individuals following a breach of unsecured protected health information.

Requests Concerning Confidential PHI and Alternative Means of Communication. You have the right to request we communicate with you about medical matters in a certain way or in a certain location. For example, you can ask that we only contact you at work or by mail. To request that we contact you in a particular way, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will support all reasonable requests. Your request must specify how or where you wish to be contacted.

VI. CONTACT.

To exercise any of the above rights, or if you have any questions or need further information, contact our Privacy Officer, , , .

VII. COMPLAINTS.

If you believe your privacy rights have been violated, we encourage you to discuss these issues with our Privacy Officer. You may file a complaint with the Privacy Officer or with the Secretary of the Department of Health and Human Services.

To file a complaint, contact the Privacy Officer at the facility that treated you. All complaints must be submitted in writing to the Privacy Officer at the address above. You will not be retaliated against for filing a complaint.

VIII. CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at our facility.

EFFECTIVE DATE:

January 01, 2023

REVISED:

January 01, 2023

We will ask that you acknowledge receipt of this Notice, because we are required to make a good faith effort to obtain your signed acknowledgement.