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.
This Privacy Notice applies to Practice Legal Name (usually referred to just as “us”, “our”, “we,” “company” or something similar).
If you have any questions about this HIPAA Notice of Privacy Practices, please contact our Privacy Officer.
I. INTRODUCTION
We understand that medical information about you and your health care is personal. We are required by law to maintain the privacy of Protected Health Information (“PHI”), to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI.
PHI includes any information that relates to:
- Your past, present, or future physical or mental health condition;
- Health care provided to you; and,
- Past, present, or future payment for your health care.
This HIPAA Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI to carry out treatment, obtain payment, or perform our health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.
We are required to follow the terms of this Notice currently in effect. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you.
II. OUR PLEDGE
The privacy of your personal health information (PHI) is important to us. Your PHI includes, but is not limited to: medical, dental, pharmacy, and mental health information. This Notice describes our privacy practices. This Notice tells you about the ways in which we may use and disclose your PHI. Also described are your rights and certain obligations we have regarding the use and disclosure of your PHI. We use and disclose your PHI in compliance with all applicable state and federal laws.
III. PROTECTED HEALTH INFORMATION IN CONNECTION WITH ALCOHOL OR DRUG SERVICES
Please note that 42 C.F.R. Part 2 protects your health information if you are applying for or receiving services (including diagnosis or treatment, or referral) for drug or alcohol abuse. Generally, if you are applying for or receiving services for drug or alcohol abuse, we may not acknowledge to a person outside the program that you attend the program or disclose any information identifying you as an alcohol or drug abuser except under certain circumstances that are listed in this Notice.
IV. HOW PHI ABOUT YOU MAY BE USED AND DISCLOSED
The following categories describe different ways that we use and disclose PHI. For each category of use or disclosure, an explanation of what is meant and some examples are provided. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose PHI will fall within one of the categories.
For Treatment. We may use or disclose your health information to provide and coordinate the mental health treatment and services you receive. For example, if your mental health care needs to be coordinated with the medical care provided to you by a physician, we may disclose your health information to a physician or other healthcare provider. Also, counselors may disclose your health information to each other to coordinate individual and group therapy sessions for your treatment. Finally, counselors may disclose information about treatment alternatives or other health-related benefits and services that are necessary or may be of interest to you.
For Payment. We may use and disclose your health information for various payment-related functions, so that we can bill for and obtain payment for the treatment and services we provide for you. For example, your PHI may be provided to an insurance company so that they will pay claims for your care.
For Healthcare Operations. We may use and disclose your health information for certain operational, administrative, and quality assurance activities, in connection with practice operations. These uses and disclosures are necessary to run the practice and to make sure that clients receive quality treatment and services. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
For Special Purposes. We are permitted under federal and applicable state law to use or disclose your PHI without your permission only when certain circumstances may arise. We may use or disclose your PHI without your permission for the following purposes:
- Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may disclose PHI to a close personal friend or family member who is involved in your medical care or payment for your care that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
- Disclosures to Parents or Legal Guardians. If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law.
- Worker’s Compensation. We may disclose your PHI to the extent authorized by and necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
- Public Health. We may disclose your PHI to federal, state, or local authorities, or other entities charged with preventing or controlling disease, injury, or disability for public health activities.
- Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for my licensure and for government monitoring of the health care system, government programs, and compliance with federal and applicable state law.
- Law Enforcement. We may disclose your PHI for law enforcement purposes as required by law or in response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a death resulting from criminal conduct; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime.
- Judicial and Administrative Proceedings. If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process, that meets the requirements of federal regulations 42 CFR Part concerning Confidentiality of Alcohol and Drug Abuse Patient Records. Please note also that if your records are not actually “patient records” within the meaning of 42 CFR Part 2 (e.g., if your records are created as a result of your participation in the program at another non-treatment setting), your records may not be subject to the protections of 42 CFR Part 2.
- United States Department of Health and Human Services. Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.
- Research. Under certain circumstances, we may use or disclose your PHI for research purposes. However, before disclosing your PHI, the research project must be approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
- Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to assist in identifying a deceased person or determine a cause of death.
- Organ or Tissue Procurement Organizations. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
- Notification. We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative, or friends may be notified about your condition, status, and location.
- Correctional Institution. If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of others.
- To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI to appropriate authorities when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.
- Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
- National Security, Intelligence Activities, and Protective Services for the President and Others. We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, provision of protection to the President, other authorized persons or foreign heads of state, and other national security activities authorized by law.
- As Required by Law. We must disclose your PHI when required to do so by applicable federal or state law.
- Health-Related Benefits and Services. We may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you.
- Appointment Reminders. We may use or disclose PHI to provide you with appointment reminders (such as voicemail messages, postcards, or letters). You have a right, as explained below, to request restrictions or limitations on the PHI we disclose. You also have a right, as explained below, to request that information be communicated with you in a certain way or at a certain location.
V. OTHER USES AND DISCLOSURES OF PHI
Your Authorization. We will obtain your written authorization before using or disclosing your PHI for purposes other than those described above (or as otherwise permitted or required by law). If you give us an authorization, you may revoke it by submitting a written notice. Your revocation will become effective upon our receipt of your written notice. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by the written authorization. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
- Notes. We will not use or disclose written notes without your written authorization, and only as permitted by law.
- Marketing Health-Related Services. We will not use or disclose your protected health information for marketing communications without your written authorization, and only as permitted by law.
- Sale of PHI. We will not sell your protected health information without your written authorization, and only as permitted by law.
If you want more information about our privacy practices or have questions or concerns, please contact us.
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