This notice describes how medical information about you may be used and disclosed and how you can get access to the information. Please review it carefully.
OUR USES AND DISCLOSURES
What is “Protected Health Information?
Your “protected health information” (PHI) is individually identifiable information, including demographic information, about your past, present, or future physical or mental health or condition, health care services you receive, and past, present, or future payment for your health care. Demographic information means information such as your name, social security number, address, and date of birth.
PHI may be in oral, written, or electronic form. Examples of PHI include your treatment record, claims record, and communications between you and your health care provider about your care.
Your PHI ceases to be PHI if it is de-identified in accordance with HIPAA standards.
About our responsibility to protect your PHI:
By law, we must:
1. Protect the privacy of your PHI;
2. Tell you about your rights and our legal duties with respect to your PHI;
3. Notify you if there is a breach of your unsecured PHI, and
4. Tell you about our privacy practices and follow our notice currently in effect.
We take these responsibilities seriously and have put in administrative safeguards (including privacy and security awareness training and policies and procedures), technical safeguards (i.e., encryption and passwords), and physical safeguards (i.e., locked areas and cabinets) to protect your PHI and we will continue to take appropriate steps to safeguard your PHI.
When it comes to your PHI, you have certain rights. This section explains your rights, how to exercise those rights, and some of our responsibilities to help you.
1. You have the right to get a copy of your health and claims records.
o You can ask to see or obtain a copy of your health records by submitting a written request. Ask us for the request form and we will provide it to you.
o You will be granted access to your treatment record within 5 business days for viewing (no copy), 15 days if you request a copy, or between 10 business days and 30 calendar days if you request or accept a treatment summary in lieu of a copy of your treatment records. We may charge a reasonable, cost-based fee.
o If you are an adult, we may only deny you access to your records if we believe your physical safety is in danger. If a parent requests access to the treatment records of their minor child, we may deny access if we believe it would be detrimental to the therapeutic relationship or the minor’s treatment and mental health.
2. You have the right to ask us to correct or amend your health treatment and claims records.
o You can ask us to correct your health treatment and claims records if you think they are incorrect or incomplete. You may make this request to your WS practitioner or to our administrative team who will then alert your practitioner.
§ We may say “no” to your request, but we’ll tell you why in writing within 60 days.
3. You have the right to request confidential communications.
o You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
o We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
4. You have the right to ask us to limit what we use or share.
o You can ask us not to use or share certain health information for treatment, payment, or our operations.
§ We are not required to agree to your request, and we may say “no” if it would affect your care.
5. You have the right to obtain a list of those with whom we’ve shared information.
o You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
o We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
o We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
6. You have the right to get a copy of this privacy notice.
o You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
7. You have the right to choose someone to act for you.
o If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
§ We will make sure the person has this authority and can act for you before we take any action.
8. You have the right to file a complaint if you feel your rights are violated.
o You can complain if you feel we have violated your rights by contacting Dr. Allison Hart, founderof Collective Light Psychotherapy, at email@example.com.
o You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
· In the following cases, you have both the right and choice to tell us to:
o Share information with your family, close friends, or others involved in payment for your care.
o Share information in a disaster relief situation.
· In the following cases, we never share your information unless you give us written permission:
o Marketing purposes
o Sales of your information
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
How We May Use and Disclose Your PHI
We are allowed by law to use and disclose your health information in certain ways and without your written or oral permission. This section briefly describes these uses and disclosures and gives some examples.
The extent of our use of your PHI will vary depending on the intended purpose of the use or disclosure. Sometimes we may only need to use or disclose a limited amount of your PHI, such as to collect payment or submit your out of network insurance claims for reimbursement purposes. At other times, we may need to use or disclose more PHI such as when we are providing psychotherapeutic treatment.
We typically use or share your health information in the following ways:
· Treatment: To help manage the mental health care you receive, we may use and disclose your PHI for diagnostic purposes and initial and ongoing evaluation of your healthcare needs and with other qualified professionals who are treating you. This may occur during consultation and supervision. We will disclose your PHI in order to provide and coordinate the care and services you need. If you need care outside of Wellspace, we may disclose your PHI to them.
· Healthcare/Organization Operations: We are permitted to use and disclose your health care information to run our practice and contact you when necessary. For example, we may use your health information to develop better services (i.e., quality assessment and improvement, training and evaluation of health care professionals, and licensing).
· Appointment Reminders: We may use your PHI to contact you about appointments for treatment or other health care you may need.
· Identity Verification: We may photograph you for identification purposes, storing the photo in your treatment record. This is for your protection and safety, but you may opt out.
· Payment for your health services: We can use and disclose your PHI to determine payment for, or to permit us to bill and collect payment for, treatment that you receive. For example, if another individual is providing payment for your treatment, we are permitted to disclose payment invoices which document the services received.
· Communications with family and others when you are present: Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell your clinician and they won’t discuss your PHI or they will ask the person to leave.
· Disclosure in case of disaster relief: We may disclose your name, city of residence, age, gender, and general condition to a public or private disaster relief organization to assist disaster relief efforts, unless you object at the time.
· Disclosure to parents as personal representatives of minors: In most cases, we may disclose your minor child’s PHI to you. In some situations however, we are permitted to or even required by law to deny your access to your minor child’s PHI. For example, when a minor who is 12 years or older and mature enough to participate in outpatient mental health therapy, they are legally allowed to consent to treatment without the consent of their parent(s), which means they retain adult rights to privacy and confidentiality, and we may only share their records with you if they approve it in writing. Another example is if you, as the parent, consented to treatment, but releasing the records to you would be detrimental to the therapeutic relationship or the minor’s health, we are permitted to deny you access.
· Healthcare oversight: As mental health providers, we are subject to oversight conducted by federal and state agencies. These agencies may conduct audits of our operations and activities in that process, that may review your PHI.
· Required by Law: In some circumstances, federal or state laws require that we disclose your PHI to others. For example, the secretary of the Department of Health and Human Services may review our compliance efforts, which may include seeing your PHI.
· Law Enforcement: We may disclose your PHI to authorized officials for law enforcement purposes, for example, to respond to a search warrant of your treatment records, report a crime on our premises, or help identify or locate someone.
· Serious threat to health or safety: We may use or disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else’s.
· Abuse or neglect: By law, we may disclose your PHI to the appropriate authority to report suspected child, elder, or dependent adult abuse or to identify suspected victims of abuse, neglect, or domestic violence.
· De-identification: We or a business associate with whom we have contracted may use PHI to de-identify it in accordance with HIPAA standards and may further disclose the de-identified data to third parties in connection with Wellspace. For example, we can share your information with our contractors and agents who help us administer our programs and policies.
· We are required by law to maintain the privacy and security of your protected health information.
· We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
· We must follow the duties and privacy practices described in this notice and give you access to or a copy of it.
· We will not use or share your information other than as described here unless you tell us we can in writing. When your authorization is required and you authorize us to use or disclose your PHI for some purpose, you may revoke that authorization by notifying us in writing at any time. Please note that the revocation will not apply to any authorized use or disclosure of your PHI that took place before we received your revocation.
· We will not take retaliatory action against you if you file a complaint about our privacy practices.
· For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html