Notice of Privacy Practices
Effective Date: March 15, 2021
This notice describes how we may use and disclose your protected health information, and your rights and choices when it comes to your information, and our obligations with respect to that information. Please review it carefully.
We create a record of the care and health services you receive to provide your care and to comply with certain legal requirements. This Notice applies to all protected health information that we generate. We follow the duties and privacy practices that this Notice describes.
If you have any questions about this notice or want information about exercising any of your rights, please contact our Compliance Officer or any staff member in our office.
A. Our Compliance Officer. Our Compliance Officer is Nina DiTommaso Morgan. You may contact our Compliance Officer at (423) 573-6836 or email@example.com.
B. Uses and Disclosures of Protected Health Information. By applying to be treated in our office, you are consenting to the use and disclosure of your protected health information by your provider, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of your provider’s practice, and any other use required by law.
PHI Defined. Your protected health information (“PHI”) is health information about you that someone may use to identify you and that we keep or transmit in electronic, oral, or written form. This includes information such as your name; contact information; past, present, or future physical or mental health or medical conditions; payment for health care products or services; and/or prescriptions.
Uses and Disclosures of Protected Health Information. The law permits or requires use to use or disclose your PHI for various reasons, as explained in this Notice. The following are some, but we have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum we need to accomplish our intended purpose.
Treatment. We may use and disclose your PHI and share it with other professionals who are treating you to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we might disclose your protected health information, as necessary, to another health care provider who
may be treating you. Your protected health information may be provided to a healthcare provider to whom you have been referred to ensure that health care provider has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from time-to-time to another health care provider (e.g., a specialist) who, at the request of your treating provider, becomes involved in your care by providing assistance with your health care diagnosis or treatment.
Payment. We may use and disclose your PHI to bill and obtain payment from health plans or others. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Health Care Operations. We may use or disclose your PHI to run our practice and improve your care. For example, we may use your PHI to manage the services you receive or to monitor the quality of our health care services and providers. We may also disclose your PHI to interns that see patients at our office.
Other Uses and Disclosures. We may share your PHI in other ways, as described below:
Business Associates. We may use and disclose your PHI to outside persons or entities perform various activities on our behalf (e.g., billing, transcription services for the practice) (“Business Associates”). Whenever an arrangement between our office and a Business Associate involves the use or disclosure of your PHI, we will have a written contract with that Business Associate that requires the Business Associate and its subcontractors to protect the privacy of your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
Legal Compliance. We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or
disclosures. This includes the disclosure of PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other
lawful process. We may also disclose PHI for law enforcement purposes, so long as applicable legal requirements are met.
Public Health. We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.
Workers’ Compensation. We may disclose your PHI for workers’ compensation claims.
Abuse or Neglect. We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI to a governmental entity if we believe that you have been a victim of abuse, neglect or domestic violence. Any such disclosure will be made consistent with the requirements of applicable federal and state laws.
Family Members Involved in Your Care. Unless you object, we may disclose your PHI to a member of your family or any other person you identify, if such information directly relates to that person’s involvement in your health care. We strive to obtain your permission to such disclosure ahead of time. However, if you are an unable to agree or object and, in our professional judgment, such disclosure is necessary for your care, we may disclose such necessary information.
Uses and Disclosures of Protected Health Information That May Be Made Only With Your Written Authorization. Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. This includes disclosures of psychotherapy notes from a private counseling session or group, joint, or family counseling session; Marketing purposes; and Selling or otherwise receiving compensation for disclosing your
PHI. You may revoke any of these authorizations, at any time, in writing, but it will not affect information that we have already used and disclosed.
Your Rights. The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.
You have the right to inspect and obtain a copy your PHI. You have the right to see or obtain an electronic or paper copy of the PHI that we maintain about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes or information complied in anticipation of, or use in, a civil, criminal, or administrative action or proceeding.
We may require you to make access requests in writing. We may charge a reasonable, costbased fee for the costs of copying, mailing, or other supplies associated with your request. You may request that we provide a copy of your PHI to a family member, another person, or a designated entity. We require that you submit these requests in writing with your signature, and clearly identify the designated person and where to send the PHI.
In the event we deny your access request, we will provide a written denial with the basis for our decision and explain your rights to appeal or file a complaint.
Please contact our Compliance Officer if you have questions about access to your PHI. You have the right to request restrictions. You have the right to ask us to limit what we use or share about your PHI. You can request that we not use or share certain PHI for treatment, payment or healthcare operations, or with certain persons involved in your care.
Your request for restriction must be in writing and state the specific restriction requested and to whom you want the restriction to apply.
We are not required to agree to Your restriction request. We may say “no” if it would affect your care. We will agree not to disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item for which you or another person, other than the health plan, paid in full out-of-pocket, unless it is otherwise required by law. Requests for a restriction must be made in writing to the Compliance Officer identified herein.
The Compliance Officer will provide you with “Restriction of Consent” form. Complete the form, sign it, and ask that the staff provide you with a photocopy of your request initialed by them. This copy will serve as your receipt.
You have the right to request confidential communications. You have the right to request that we communicate with you about health matters in a certain manner or at a certain location. For example, you can ask that we only contact you at work or at a specific address. We will accommodate reasonable requests. We will not request an explanation from you as to the basis for the request. These requests must be made to us in writing.
You may have the right to request amendments to your PHI. You may ask us to correct or amend PHI that we maintain about your that you think is incorrect or inaccurate. These requests must be made to us in writing, and must specify the inaccurate or incorrect PHI and provide a reason that supports your request. We may deny your request for an amendment if you ask us to amend PHI that is not part of our record, that we did not create, that is not part of a
designated record set, or that is accurate and complete. If we deny your request for amendment, we will tell you why in writing. You will have the right to submit a written statement of disagreement with the denial and, and we may prepare a written rebuttal to your statement.
Please contact our Compliance Officer if you have questions about amending your medical record.
You have the right to request an accounting of disclosures. You have the right to request an accounting of certain PHI disclosures that we have made. This right applies to disclosures made for purposes other than treatment, payment, or healthcare operations as described in this Notice. This right also does not apply to disclosures we may have made to you or family members involved in your care pursuant to a duly executed authorization.
This right relates disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limits. We will provide one accounting a year for free, but we may charge a reasonable, cost-based fee if you ask for another accounting within twelve months. We will notify you about the costs in advance, and you may choose to withdraw or modify your request at that time.
You have the right to notification about a data breach. In compliance with applicable federal and state laws, you have the right to prompt written notification alerting you to any discovery of any breach of your unsecured PHI or in cases where we reasonably believe that your PHI has been accessed, acquired, used or disclosed to an unauthorized party. With your written consent, we may provide you with an electronic notification which will be sent to the email address you provided to us for contact and communication purposes when you registered to receive therapeutic services from us. This consent is provided in accordance with Section 164.404 (d) (1)(i) of HIPAA. You may withdraw your consent for electronic notification under this section at any time by contacting our offices and speaking to any of our representatives. If we do not have your written consent to notify you, or you revoke this consent to notify you by email, then you will be notified by letter via U.S. Mail.
You have the right to request a paper copy of this notice from us, even if you have agreed to accept this notice electronically.
You have the right to make Complaints. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may file a complaint directly with us by contacting our Compliance Officer, or with the Office for Civil Rights at the US Department of Health and Human Services (“DHS”). For information regarding how to file a Complaint with DHS, please visit: https://www.hhs.gov/hipaa/filing-a-complaint/complaint-pro-cess/index.html.
Changes to this Notice. We can change the terms of this Notice, and the changes will apply to all information that we have about you. The new notice will be available on request, in our office, and on our website.