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!
USE AND DISCLOSURE FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
State and federal laws require us to maintain the privacy of your protected health information and to inform you about our privacy practices and legal duties with respect to protected health information by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on July 1, 2016, and will remain in effect until it is amended or replaced by us.
It is our right to change our privacy practices provided that applicable law permits such changes. Before we make a material change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.
You may request a copy of our Privacy Notice at any time by contacting our office.
We may use or make disclosures of your PHI for Treatment, Payment, and Health Care Operations purposes with your prior written consent. We have included definitions below to help clarify the capitalized terms used herein.
Protected Health Information or (PHI) is information in a patient’s health record about a patient’s age, race, sex, and other personal health information that may identify the patient. The information relates to the patient’s physical or mental health in the past, present, or future, and to the care, treatment, and services needed by a patient because of his or her health.
Treatment occurs when we provide, coordinate or manage your mental health care and other services related to your mental health. “We” includes the professional staff of Success Health System, LLC : psychologists, psychiatrists, social workers, therapists, and administrative staff assistants.
Payment occurs when we obtain reimbursement for your healthcare. Examples of payment are when we disclose PHI to an insurance company to obtain reimbursement for your healthcare or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
Use applies only to activities within our practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside our practice, such as releasing, transferring, or providing access to information about you to other parties.
TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION WHERE NO AUTHORIZATION IS REQUIRED
– We may disclose your PHI without your prior written authorization for the following purposes:
Emergency: We may use or disclose your PHI in response to an emergency medical situation when release of PHI is necessary to prevent serious risk of bodily harm or death. Only specific information pertinent to the relief of the emergency may be released without your consent.
Duty to Warn: If you communicate a specific and immediate threat of serious bodily injury to us and such threat is made against a specifically identifiable or readily identifiable victim, then we have the duty under the law to warn such victim. Carrying out our duty to warn may involve the disclosure of PHI without your consent.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release the PHI without your written authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
Abuse or Neglect: If we have reasonable cause to suspect, on the basis of our medical, professional, or other training and experience, that you are the possible victim of child abuse, we have the right to disclose your PHI to the Department of Public Welfare. If we have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides such protective services.
There may be additional disclosures of PHI that we are required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.
USES AND DISCLOSURES REQUIRING AUTHORIZATION
Authorization: To release your PHI to other people for any reason other than Treatment, Payment, and Health Care Operations or as required by or permitted by law, then we must obtain written authorization from you consenting to such use or disclosure. If you give us an authorization, you may revoke it in writing at any time. We will, however, continue to use or disclose your PHI pursuant to such authorization to the extent that we have already acted in reliance on this authorization. Revocation will not apply to your insurance company when the law provides that your insurer has the right to contest a claim under your policy. For example, the following information will NOT be disclosed without your authorization:
§ Psychotherapy notes and/or other types of PHI related to such therapy;
§ Use of your PHI for our marketing purposes, including subsidized Treatment communications;
§ Any disclosures that constitute a sale of your PHI; and
§ Any other uses or disclosures not already described in this Notice.
YOUR PRIVACY RIGHTS AS OUR PATIENT
Right to Access and Copy Records: You have the right to inspect and copy your PHI by using a written request form and submitting such form to our office. There are limited exceptions to this right. Upon your request, you may receive this information in an electronic format if such a copy is readily producible. You may be charged a reasonable fee for the cost of copying your records, as mentioned in our payment plans.
Amendment: You have the right to amend your PHI, if you feel it is inaccurate or incomplete. Your request must be made to our office in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Right to an Accounting of Disclosures: You have the right to request an “account of disclosures” of your PHI. This is a list of disclosures we made of PHI about you, other than for Treatment, Payment or Health Care Operations as described in this Notice. We are not required to account for information releases that you request, that you agree to by signing an authorization form, or certain releases that we are allowed to make without your permission. The request for an accounting must be made in writing to our officer. The request should state the time period for the accounting. Requests for records about our disclosures of your PHI are limited to a time period as required by law. You may be charged a fee for the cost of compiling this accounting.
Right to Request Limits on Use or Disclosure of PHI: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We do not have to agree to these additional restrictions, unless you request us not to disclose PHI to your health plan with respect to a health care item or service for which you have paid in full out of pocket. If we do agree to such restriction, we will abide by our agreement unless the PHI is needed to provide you emergency Treatment. Please contact our office if you want to further restrict access to your health care information. This request must be submitted in writing.
Right to Choose How We Communicate with You: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make a request in writing to our office. Your request must specify how or where you wish to be contacted. We will not ask you the reason for the request. We will attempt to accommodate all reasonable requests.
Right to Receive Notifications of Data Breach: You have the right to and will receive notification of breaches of your unsecured PHI.
HIPPA Notice of Private Practice
This Form Does NOT Constitute Legal Advice. Please Consult a Qualified Attorney, if necessary.