Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected health Information (“PHI”) in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”) and regulation promulgated under HIPAA, including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy upon request or provide one to you at your next appointment.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is minimally necessary.
HOW YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED
Reasons I may have to release your information without authorization:
• For Treatment – I may use and disclose your health information internally in the course of your treatment and for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.
• For Payment –I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for the purposes of collection.
• For Operations –I may use or disclose, as needed, your PHI to support our business activities including, but not limited to, quality assessment activities, therapist or staff review activities, licensing, and conducting or arranging for other business activities. For training or teaching purposes PHI will be disclosed only with your authorization.
· Required by Law – Under the law, I must disclose your PHI to you upon your request, subject to some exceptions. In addition, I must make disclosures to the Department of Health and Human Services for the purpose of investigation or determining my compliance with the requirements of the Privacy Rule.
The following is a list of categories of uses and disclosure permitted by HIPAA without authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.
1. Judicial and Administrative Proceedings -- If you are involved in a court proceeding and a request is made for information concerning your PHI. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena.
2. Health Oversight Activities -- If a government agency is requesting information for health oversight activities authorized by law, such as audits, investigations, and inspections.
3. Litigation -- If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
4. Workers’ Compensation Claims -- If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I may submit PHI, including the patient's employer, the insurance carrier, or an authorized qualified rehabilitation provider.
5. Business Associates -- I may disclose the minimum necessary health information to my business associates that perform functions on my behalf or provide me with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
6. Abuse or Neglect -- If I know, or have reason to suspect, that a child under 18 or a vulnerable adult has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Michigan Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
7. Potential Harm to Patient or Others -- If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient. I may use or disclose your PHI in a medical situation to medical personnel in order to prevent serious harm.
8. Family Involvement in Your Care – I may disclose information to a close family member or friend who is directly involved in your treatment as necessary to prevent serious harm.
9. Law Enforcement – I may disclose PHI to a law enforcement official, as required by law, in compliance with a subpoena, court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
RELEASE OF PHI WITH AN AUTHORIZATION
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (a) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical records; (b) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (c) disclosures constitute a sale of PHI; and (d) other uses and disclosures not described in this Notice of Privacy Practices.
Client Rights: You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to April Mendyka, MA, LPC at April@ChooseToTransform.com or call (586) 381-7835.
• Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
• Right to Confidentiality – You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition of accommodating your request. We will not ask you for an explanation of why you are making the request.
• Right to Request Restrictions – You have the right to request restrictions or limitations on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purpose of carrying out payment or health care operations, and the PHI pertains to a health care items or service that you paid for out of pocket. In that case, we are required to honor your request for restriction.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI maintained in a “designated record set”. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. Records must be requested in writing and the release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
• Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. I am not required to agree to the amendment. If I deny your request for an amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. You have to make this request in writing. You must tell us the reasons you want to make these changes.
• Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time. This Notice of Privacy Practices may also be downloaded off my website.
• Right to an Accounting – You generally have the right to request receive an accounting of disclosures of PHI regarding you. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
· Breach Notification – If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
COMPLAINTS
If you are concerned that I have violated your privacy rights, you have the right to file a complaint in writing with April Mendyka, MA, LPC or with the Secretary of the Health and Human Services Department at 200 Independence Avenue, S.W., Washington, D.C. 2021 or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.
Download a copy here.