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.
Our Duty to Safeguard Your Protected Health Information
Identifiable information about your past, present, or future health, the provision of health care or payment for health care is considered “Protected Health Information” (PHI). We are required to extend certain protections to your PHI and to give you this notice about privacy practices that explain how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.
Additional copies of this notice are available in the waiting room.
How We May Use and Disclose Your Protected Health Information
We use and disclose PHI for a variety of reasons. We have a limited right to use and/or disclose your PHI for purposes of treatment, payment and for our health care operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity to perform a function on our behalf, we must have in place an agreement from that entity that it will extend the same privacy protection to information that we must apply to your PHI. However, the law provides that we are permitted to make some disclosures without consent or authorization. The following describes and offers examples of our disclosures of your PHI.
Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations
For Treatment: We may disclose your PHI to doctors or other health care personnel who are involved in providing your health care.
To Obtain Payment: We may disclose your PHI in order to bill and collect payment for your health care services.
For Health Care Operations: We may be required to provide information to a government agency for study. This is highly unlikely but if it were to occur, your name will be removed from what is sent.
Uses and Disclosures of PHI Requiring Authorization
For disclosure beyond treatment, payment and operations purposes we are required to have your written authorization, unless the disclosure falls within one of the exceptions described below. Authorization can be revoked at any time to stop future disclosures except to the extent that we have already acted upon your authorization.
Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent
When Required by Law: We must disclose PHI to report suspected abuse, lawsuits or other legal proceedings where we have received a subpoena and to government agencies monitoring HIPAA compliance.
To Avert Threat to Health or Safety: In order to avoid a serious threat to health or safety, we must disclose PHI as necessary to law enforcement or other persons who can reasonably present or lessen the threat of harm.
For Specific Government Functions: We must disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment, Workers’ Compensation programs and for national security.
Your Rights Regarding Your Protected Health Information
You have the following rights relating to your protected health information:
To Request Restrictions on Disclosures: You have the right to ask that we limit how we disclose your PHI. We will consider your request, but are not legally bound to agree. To the extent that we do agree, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit disclosures that are required by law.
To Inspect and Request a Copy of PHI: Unless access to your
records is restricted for clear and documented treatment reasons, you
have a right to see your PHI upon written request. If you request
copies of your PHI, a charge for copying may be imposed, depending on
your circumstances. You have a right to choose what portions of your
information you want copied.
To Request Amendment of Your PHI: If you believe there is a mistake or missing information in your PHI, you may request, in writing, that we correct the record. We will respond within 60 days. We may deny the request if we determine the PHI is:
1. Correct and complete;
2. Not created by us;
3. Not permitted to be disclosed. Any denial will state the reasons for denial.
To Find Out What Disclosures Have Been Made: You have a right to receive a list of when, to whom, for what purpose and what content of your PHI has been released other than instances of disclosure: for treatment, payment and operations; to you, your family, or pursuant to your written authorization. Your request can relate to disclosures going as far back as seven years.
Couples Counseling: In regards to couples counseling, confidentiality belongs to both parties. No information will be released unless a signed consent form is received from both parties.
If you believe we have violated your privacy rights you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services. A complaint will not affect your quality of care with us.
If you have questions about this Notice, please contact our Clinical Manager at phone at 503-253-0964. Our ethical commitment to your privacy goes beyond federal law. We will make every effort to inform you of routine disclosures.