Notice of Privacy Practices for Psychotherapy

HIPIAA

Your Information. Your Rights. Our Responsibilities.

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.

You have the right to: 

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

You have some choices in the way that we use and share information as we: 

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds

We may use and share your information as we: 

• Provide services to you

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Respond to lawsuits and legal actions

When it comes to your health information, you have certain rights. 

This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record 

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. 

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• 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. 

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• 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.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• 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.

• We will include all disclosures except those related to treatment, payment, and healthcare operations, as well as certain other disclosures (such as any you have requested us to make). 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.

Get a copy of this privacy notice

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.

Choose someone to act for you

• 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 ensure that the person has the necessary authority and can act on your behalf before taking any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information below.

• 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, please let us know. Please let us know what you would like us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are unable to express your preference, for example, if you are unconscious, we may proceed to 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.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can opt out of future contact requests.

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use your health information to manage your treatment and services. 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. 

Example: We provide information about you to your health insurance plan so that it can cover your services. 

We are permitted or required to share your information in other ways, such as presentations without identifying information, typically in ways that benefit the public good, including public health and research. We must meet several conditions under the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations, such as: 

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We may use or share your information for health research purposes. You will receive a consent form if that's the case.

Comply with the law

We will share information about you if local, state, or federal laws require it, including with the Department of Health and Human Services, if it requests confirmation that we’re complying with federal privacy laws.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or a funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

• 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 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.