Notice of Privacy Practices

HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date: [Date]

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices (“Notice”) apply to [Practice Name], its affiliates, and its employees. [Practice Name] will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.

I am required by law to maintain the privacy of my patients' protected health information and to provide patients with notice of my legal duties and privacy practices with respect to protected health information. I am required to abide by the terms of this Notice for as long as it remains in effect. I reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Leslie Crane Therapy. I am required to notify you in the event of a breach of your unsecured protected health information. I am also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION:

Authorization and Consent: Except as outlined below, I will not use or disclose your protected health information for any purpose other than treatment, payment or healthcare operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that I have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.

Uses and Disclosures for Treatment: I will make uses and disclosures of your protected health information as necessary for your treatment. Psychiatrists, doctors, nurses, and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment which may include procedures, medications, tests, medical history, etc.

Uses and Disclosures for Payment: I will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, I may forward information regarding your mental health treatments and treatment to your insurance company to arrange payment for the services provided to you. I may also use your information to prepare a bill to send to you or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations: I will make uses and disclosures of your protected health information as necessary, and as permitted by law, for my health care operations, which may include clinical improvement, professional peer review, business management, accreditation, and licensing, etc. For instance, I may use and disclose your protected health information for purposes of improving clinical treatment and patient care.

Individuals Involved In Your Care: I may from time to time disclose your protected health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and I determine that a limited disclosure may be in your best interest, I may share limited protected health information with such individuals without your approval. I may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as billing, auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for me to provide your protected health information to one or more of these outside persons or organizations who assist me with my healthcare operations. In all cases, I require these associates to appropriately safeguard the privacy of your information.

Appointments and Services: I may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and I will accommodate reasonable requests by you to receive communications regarding your protected health information from me by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, I will accommodate reasonable requests. With such request, you must provide an appropriate alternative address or method of contact. You also have the right to request that I not send you any future marketing materials and I will use my best efforts to honor such request. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below.

Research: In limited circumstances, I may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of your information.

Other Uses and Disclosures: I am permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:

  • Any purpose required by law;

  • Public health activities as required by law in connection with public health investigations;

  • If I suspect child abuse or neglect I am mandated to report this to Oklahoma Child Welfare by law; if I suspect you to be a victim of abuse or neglect;

  • To your employer when I have provided health care to you at the request of your employer;

  • To a government oversight agency conducting audits, investigations, civil or criminal proceedings;

  • Court order or court-ordered subpoena

  • To law enforcement officials as required by law if I believe you have been the victim of abuse or neglect. I will only make this disclosure if you agree or when required or authorized by law;

  • To coroners and/or funeral directors consistent with law;

  • To workers' compensation agencies for workers' compensation benefit determination.

  • To first responders in the event of a medical or life-threatening emergency.

DISCLOSURES REQUIRING AUTHORIZATION:

Psychotherapy Notes: I must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which I may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for my own training, and to defend myself in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine my compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.

Genetic Information: I must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment or health care operations purposes. I may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law.

Marketing: I must obtain your authorization for any use or disclosure of your protected health information for marketing

Sale of Protected Information: I must obtain your authorization prior to receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for:

  • Public health activities;

  • Research purposes, provided that I receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes;

  • Treatment and payment purposes;

  • Health care operations involving the sale, transfer, merger or consolidation of all or part of my business and for related due diligence;

  • Payment I provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on my behalf (or the subcontractor undertakes on behalf of a business associate) and the only remuneration provided is for the performance of such activities;

  • Providing you with a copy of your health information or an accounting of disclosures;

    Disclosures required by law;

  • Disclosures of your health information for any other purpose permitted by and in accordance with the Privacy Rule of HIPAA, as long as the only remuneration I receive is a reasonable, cost-based fee to cover the cost to prepare and transmit your health information for such purpose or is a fee otherwise expressly permitted by other law; or

  • Any other exceptions allowed by the Department of Health and Human Services.

RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that I retain on your behalf. For protected health information that I maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made in writing and signed by you or your legal representative. You may obtain a "Patient Access to Health Information Form" from me. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies you will be charged a fee for copying and postage.

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that I maintain about you be amended or corrected. I am not obligated to make requested amendments, but I will give each request careful consideration. All amendment requests, must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, I may notify others who work with me if I believe that such notification is necessary. You may obtain an "Amendment Request Form" from me.

Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by me of your protected health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. "Accounting Request Forms" are available from me. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.

Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. I am not required to agree to most restriction requests, but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid Leslie Crane Therapy in full. If I agree to any discretionary restrictions, I reserve the right to remove such restrictions as I find appropriate. I will notify you if I remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records.

Right to Notice of Breach: I take very seriously the confidentiality of my patients’ information, and I am required by law to protect the privacy and security of your protected health information through appropriate safeguards. I will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.

Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to me at the address below.

Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with me. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint.

Office for Civil Rights Department of HHS
Jacob Javits Federal Building 26 Federal Plaza - Suite 3312 New York, NY 10278
Voice Phone (212) 264-3313 FAX (212) 264-3039
TDD (212) 264-2355

For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact [Practice Name] by phone at [Practice Phone Number] or at the following address: [Practice Address].