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Notice of Privacy Practices & Professional Disclosure Statement

Purpose:  Your protected health information (PHI) is any information we have about your that may identify you, and that relates to the mental health treatment provided to you, the payment for these services, and your mental health condition in the past, present, or future.  This Notice of Privacy practices describes how we may use and disclose your PHI for the purposes of treatment, payment, and healthcare operations and it also describes your rights to access your PHI.

Definition of Treatment, Payment, and Health Care Operations: To maximize your mental health services, the clinician may need to share your mental health records with other designated professionals, i.e. diagnosis, treatment dates, etc., in order to coordinate your care.  My billing service is Mountain Medical Services.  In order to receive third party reimbursement, a diagnosis, dates and length of service are usually required.

Use and Disclosure of Protected Health Information:  This clinician will use and disclose your protected health information to carry out treatment and payment for treatment.  Further, as allowed by Federal and State law, this clinician may use and disclose your protected health information without your written consent or authorization under the following circumstances:

  • To a personal representative legally designated by you to receive you PHI, or a personal representative designated by law, such as a parent/legal guardian of a child.
  • When a disclosure is required by federal, state, or local law, judicial or administrative proceeding, or law enforcement.  For example, I may disclose information about suspected child or elderly abuse and/or neglect, or when ordered by judicial or administrative proceedings, or to report criminal activities.
  • To a health oversight agency for activities authorized by law such as audits, investigations, inspections, licensure or disciplinary proceedings, etc.
  • For public health activities such as for the purpose of preventing or controlling communicable diseases, or for providing coroners and medical examiners information related to an individual’s death.
  • To prevent a serious identifiable threat to health or safety (yourself or others).

Other disclosures Requiring Your Authorization:  Except as described in previous sections, this clinician will not use or disclose your protected health information without your written authorization.  You may revoke this authorization at any time, except to the extent that the use or disclosure has already occurred.

Your Rights Regarding the Use and Disclosure of Your Protected Health Information: You have the following rights regarding protected health information:

  • Right to request restriction.  You may request restrictions on the use and disclosure of your protected health information, but this clinician is not required to agree to your request.  If the restriction is granted, the clinician will comply with the request unless it is necessary to use or disclose information to provide you or your minor child/children with emergency treatment.
  • Right to inspect and copy your protected health information.  You may request, in writing, to inspect and copy your health information, with the exception of therapy notes or information that has been provided by a third party.  The clinician may charge a fee for copying, as well as postage if mailed.  Under certain circumstances your request may be denied, for example, if the request is contraindicated to treatment.
  • Right to request an amendment of, or change to, your protected health information.  If you believe that your health information is incorrect or incomplete, you may request an amendment to the information.  The clinician will consider the request, but is not required to comply with your request.
  • Right to receive an accounting of disclosures of your protected health information.  You may request a list of disclosures of your health information that have been made other than for treatment, payment, or health care operations.
  • Right to obtain a paper copy of the Notice of Privacy Practices upon request.  You may request a copy of this notice at any time.

Requirements Regarding this Notice of Privacy Practices:  This clinician is required by law to maintain the privacy of protected health information and to provide you with the Notice of Privacy Practices.  This clinician reserves the right to change the terms of this Notice.  When these changes occur, the changes will be effective for all health information we currently maintain for you as well as any information received about you in the future.  When changes to this Notice are made, a revised Notice will be made available to you at your request.