Notice of Privacy Practices - Behavioral Health

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: This notice is effective as of the date signed by the client.

I. Pledge Regarding Health Information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

1. Make sure that protected health information (“PHI”) that identifies you is kept private.

2. Give you this notice of my legal duties and privacy practices with respect to health information.

3. Follow the terms of the notice that is currently in effect.

I am also required by law to provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. How We May Use and Disclose PHI

• For Treatment, Payment, or Health Care Operations: Federal privacy rules allow health care providers who have direct treatment relationships with the client to use or disclose the client’s PHI without written authorization to carry out their own treatment, payment, or health care operations. I may also disclose your PHI for the treatment activities of any health care provider without written authorization. For example, if a clinician were to consult with another licensed provider about your condition, we would be permitted to disclose PHI to assist in diagnosis and treatment. (If records are protected under 42 C.F.R. Part 2, certain uses/disclosures are materially limited by those stricter standards. Information disclosed may be subject to redisclosure by the recipient and no longer protected by federal privacy standards).

• Minimum Necessary Exception: Disclosures for treatment purposes are not limited to the minimum necessary standard. The word “treatment” includes coordination and management of health care providers with a third party, consultations, and referrals.

• Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose PHI in response to a court or administrative order. I may also disclose PHI about your child in response to a subpoena, discovery request, or other lawful process, but only if efforts have been made to tell you about the request or to obtain an protective order. For records protected by 42 C.F.R. Part 2, such records/testimony shall not be used or disclosed in proceedings against you unless you provide specific written consent or a court order is issued.

III. Uses and Disclosures Requiring Your Authorization

• Psychotherapy Notes: Any use or disclosure of psychotherapy notes (notes kept separate from your medical record) requires your Authorization unless the use/disclosure is: for my use in treating you; training or supervising practitioners; defending myself in legal proceedings instituted by you; investigation of my compliance by HHS; required by law; coroner performing duties; or to help avert a serious threat to the health and safety of others.

• Substance Use Disorder (SUD) Counseling Notes: Any use or disclosure of SUD counseling notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that I have already acted upon it.

• Marketing Purposes: As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

• Sale of PHI: As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. Uses and Disclosures NOT Requiring Your Authorization

Subject to limitations, I can disclose your PHI without your Authorization for:

1. State or federal law compliance.

2. Public health activities (reporting suspected child, elder, or dependent adult abuse, or preventing serious threats to anyone's safety).

3. Health oversight activities, including audits and investigations.

4. Judicial and administrative proceedings (court/administrative orders).

5. Law enforcement purposes (crimes on premises).

6. Coroners or medical examiners performing duties.

7. Research purposes.

8. Specialized government functions (military missions, presidential protection, intelligence, correctional safety).

9. Workers' compensation purposes.

10. Appointment reminders and health-related benefits or services.

V. Disclosures Requiring Opportunity to Object

• Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or payment, unless you object in whole or in part (obtained retroactively in emergencies).

• Fundraising: If I intend to use or disclose your records protected by 42 C.F.R. Part 2 for fundraising for my benefit, I will provide you with a clear and conspicuous opportunity to opt-out before any such use or disclosure occurs.

VI. Your Rights with Respect to Your PHI

• Right to Request Limits: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or operations. I am not required to agree if it affects your care.

• Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full: You have the right to request restrictions on disclosures to health plans if the PHI pertains solely to a health care item or service that you have paid for out-of-pocket in full.

• Right to Choose Communications: You have the right to ask me to contact you in a specific way or at a different address, and I will agree to all reasonable requests.

• Right to See and Get Copies: Other than psychotherapy notes and SUD counseling notes, you have the right to get an electronic or paper copy of your medical record within 30 days of a written request, subject to a reasonable, cost-based fee.

• Right to a Disclosure List: You have the right to request a list of disclosures made in the last six years (excluding treatment, payment, operations, or authorized releases). The first request is free.

• Right to Correct or Update: You have the right to request corrections or updates to your PHI. I may say no, but will explain why in writing within 60 days.

• Right to Paper/Electronic Copy of Notice: You have the right to a paper copy of this notice at any time.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Client Full Name * Required

Client Signature * Required

Signature

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Notice of Privacy Practices - Behavioral Health

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