Notice of Privacy Practices
620 Stoneglen Drive Suite B, Keller TX 76248
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR COMMITMENT REGARDING HEALTH INFORMATION:
Redefine is dedicated to maintaining the privacy of your Protected Health Information (PHI) in our mental health records. In conducting our business, we will create records regarding you and the treatment and the services we provide to you. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our office concerning your PHI. Any revisions to this notice will be posted in a visible location in our offices.
As required by the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Should you have any questions, please contact us via email at email@example.com. Please review this notice carefully.
If you have any questions about this notice, please contact:
Diana Bigham, Privacy Officer
620 Stoneglen Drive Suite B, Keller TX 76248
II. HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU:
1. Treatment: Our practice may use your PHI to treat you. For example, we may use your PHI to coordinate health care with your doctor or hospital in case of emergency or internally for clinical supervision purposes.
2. Payment: We may use and disclose information to your insurance company if you have asked us to bill for third-party reimbursement.
3. Releases: When you have signed a written release, we may contact the designee without your direct knowledge until the date that release expires. You have the right, though, to change your mind at any point and revoke the release.
Appointment Coordination: Redefine may use your PHI to contact you to remind you of an appointment or to reschedule appointment times. For example, we use your phone number and/or email to send you appointment reminders.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For our use in treating you.
b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For our use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, we will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, we will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health risks, including reporting suspected child, elder, or dependent adult neglect or abuse, or preventing or reducing a serious injury, threat, or disability to anyone’s health or safety, and reporting reactions to drugs or problems with products or devices. We may also notify appropriate government agencies and authorities regarding the potential abuse or neglect of an adult (including domestic violence); however, we only disclose if the client agrees or we are required by law.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so. We also may have to disclose your PHI in response to a subpoena or discovery request.
For law enforcement purposes by law officials, including reporting crimes occurring on my premises, regarding a crime victim in certain situations if we are unable to obtain the person’s agreement, concerning a death we believe has resulted from criminal conduct, regarding criminal conduct at our offices, in response to a warrant, summons, court order or subpoena, to identify/locate a suspect, material witness, fugitive or missing person, in an emergency to report a crime (including the location of victims of a crime, identity, or location of a perpetrator).
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. we may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
- Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
Confidential Communications: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than at work. Please ask your clinician to specify your request. We will agree to all reasonable requests.
Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your PHI. We are not required to agree, but if we do then we are bound to our agreement. Talk to our Privacy Officer, Diana Bigham at 817-562-8800 or firstname.lastname@example.org if there is information that you wish to be restricted then we are bound to our agreement.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
Inspection of Copies: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient records and billing records, but not psychotherapy notes. Contact our Privacy Officer for copies of your records. In limited situations, this request may be denied, if this is not in your best interest as decided by your doctor and/or clinician. Mediation from another health care professional will be made available in this case if requested. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and may charge a reasonable, cost based fee for doing so.
Right To Amend: You may ask us to change your records if you feel that there is a mistake, or that a piece of important information is missing from your PHI. We can deny your request for certain reasons, but we must give you a written reason for our denial within 60 days of receiving your request.
You Have The Right To An “Account Of Disclosures”: You may ask for a list of all disclosures that were made after April 14, 2003. The list will not include the times that information was disclosed regarding treatment, payment, health care operations, or information given to you or others by your own authorization. We may respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
You Have The Right To File A Complaint: If you believe that your privacy rights have been violated, you may file a complaint with our privacy officer Diana Bigham at 817-562-8800 or email@example.com or with the Department of Health and Human Services at (800) 368-1019.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 20, 2013
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.