I am required by law and am committed to protecting your private personal information, which may be personal information collected from you. I am required by law and am committed to protecting your private personal information, which may be personal information collected from you, information about healthcare we provide to you, or payment of healthcare provided for you. I will only use and disclose your personal information as necessary to provide you with behavioral healthcare. I am also required by law to provide you with this Notice of Privacy Practices explaining my legal duties and privacy practices with respect to information. I am legally required to follow the terms of this notice. The terms of this notice may change in the future as allowed by law. If this notice is changed, the new privacy practices will apply to your information that I already possess, as well as future information. If the changes are made to the notice, I will post the new notice in the reception area, on my website, and will have copies available upon request.
Uses and Disclosure of Protected Healthcare Operations
I routinely use your health information inside my office in order to provide behavioral healthcare and to obtain payment for that healthcare. For example: I may use and disclose medical information about you to obtain payment for behavioral healthcare services. This may incorporate releasing your protected health information to submit for payment of claims delivered to you or your insurance carrier. Or I may use and disclose protected personal information such as your name, contact information, and amount due to collection agencies in efforts to collect payments on delinquent accounts.
Required by Law/Public Health Activities
I may use and disclose medical information about you to the full extent that public health activities are permitted by law. For example, I may use or disclose information for the purpose of preventing or controlling disease, injury or disability.
Abuse or Neglect/Harm of Self or Others
I may disclose or receive your protected health information to a government authority that is authorized by law to receive reports of abuse or neglect as I may be obligated by law to make such reports. Or I may disclose your protected health information if I believe that the disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person, the public, or harm to oneself.
I may disclose your protected health information in the course of any judicial proceeding, in response to an order of a court tribunal, and in response to a subpoena or other lawful process.
Others Involved in your Healthcare
I may disclose your protected health information to a designated friend, family member, or guardian (parents/guardian for minors) if previously agreed that the individual is involved in your healthcare.
Right to Access
You have the right to look at or get copies of your protected health information which generally includes medical and billing records as well as decisions made about your healthcare. However, you may not be able to inspect or copy any psychotherapy or case file notes. If desired, a typed summary of notes can be provided to you upon special arrangement and according fees from the provider.
Right to Restriction
You have the right to request a restriction on the protected health information we use or disclose about you for treatment, payment or other healthcare operations. I will abide by the agreement unless the information is needed to provide emergency treatment to you. Any agreement of restrictions will be in writing.
Information I Collect
I collect information about the patient, parent or guardian either directly or through a chosen party or administrator. This information includes personal data provided on intake questionnaires or behavior symptom questionnaires that may include such information as your name, social security number, date of birth, marital status, dependent and employment/school information. It may also include other healthcare or school information submitted to me by other agencies or institutions upon your request. Information may also include payment claims submitted, a diagnosis code, services provided, charges and amounts paid.
How Information is Protected
Protected health information is available only to the providing clinician, consultants or other providers involved in treatment, and third party billing agents. I maintain physical, electronic, and procedural safeguards that comply with state and federal regulations to guard personal financial information from unauthorized access, use and disclosure.
If you think that I have not properly respected the privacy of your information you are free to submit a grievance to this clinician or the US Department of Health and Human Services Office for Civil Rights. I will not retaliate against you if you make a complaint.