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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO ME. In effect as of March 24, 2003
WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by me and my staff.. The practices described in this notice will also be followed by any other therapist who provides "call coverage" for me if I am not available.
YOUR HEALTH INFORMATION
This notice applies to the information and records I have about your health, health status, and the health care and services you receive at this office. I am required by law to give you this notice. It will tell you about the ways in which I may use and disclose health information about you and describes your rights and my obligations regarding the use and disclosure of that information
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
I use and disclose health information about you for treatment, payment and healthcare operations. For example:
For Treatment I may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
For Payment I may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party.
For Health Care Operations I may use and disclose health information about you in order to run the office and make sure that you and my other patients receive quality care. For example, I may use your health information to evaluate the performance of my staff in caring for you.
Appointment Reminders I may contact you as a reminder that you have an appointment at the office. Please notify me if you do not wish to be contacted for appointment reminders.
Required By Law I will disclose health information about you when required to do so by federal, state or local law.
Family and Friends I may disclose health information about you to your family members, friends or another person, only if I obtain written authorization to do so. If you bring another person into a therapy session I may assume you agree to my disclosure of your personal health information during the session.
National Security and Intelligence I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.
To Avert a Serious Threat to Health or Safety I may disclose you health information to appropriate authorities If I reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
I will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. I must obtain your Authorization separate from any Consent I may have obtained from you. If you give me Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, I will no longer use or disclose information about you for the reasons covered by your written Authorization, but I cannot take back any uses or disclosures already made with your permission.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information I maintain about you:
Right to Inspect and Copy You have the right to inspect and copy your health information, such as therapy and billing records, that I use to make decisions about your care. Psychotherapy notes are specifically excluded and you do not have a right to inspect or copy them. You must submit a written request in order to inspect and/or copy your health information. If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other associated supplies. I may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, I will select a licensed health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.
Right to Amend If you believe health information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Medical Record Amendment/Correction Form. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that: a) I did not create, unless the person or entity that created the information is no longer available to make the amendment. b) Is not part of the health information that I keep. c) You would not be permitted to inspect and copy. d) Is accurate and complete.
Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures I made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. If you request this accounting more than once in a 12-month period I may charge you for the costs of providing the list.
Right to Request Restrictions You have the right to request additional restrictions on my use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do , I will abide by our agreement (except in an emergency). To request restrictions, you must complete and submit the Request For Restriction On Use/Disclosure Of Medical Information form.
Right to Request Confidential Communications You have the right to request that I communicate with you about your health information in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail. To request confidential communications, you must complete and submit the Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication form.. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.
CHANGES TO THIS NOTICE
I reserve the right to change this notice provided such changes are permitted by applicable law, and to make the revised or changed notice effective for health information I already have about you as well as any information I receive in the future. I will post the current notice in my office. You are entitled to a copy of the notice currently in effect.
QUESTIONS AND COMPLAINTS
If you want more information about my privacy practices or have questions or concerns, please contact me. If you believe your privacy rights have been violated, or you disagree with a decision I made about your health information in response to a request, you may file a complaint with me or with the Secretary of the Department of Health and Human Services. To file a complaint with me use the, contact information below. I will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. You will not be penalized for filing a complaint.
Contact Officer: Nike F. Carli, LCSW-R
Telephone: 716-633-6900 / Fax: 716-633-6902 / Email: firstname.lastname@example.org
Address: 5500 Main Street, Suite 207, Williamsville, New York 14221
(This Form is educational only, does not constitute legal advice, and covers only federal, not state, law in effect or proposed as of March 24, 2003, Subsequent law changes may require Form revision.)