THIS NOTICE PROVIDES YOU WITH INFORMATION ABOUT HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED BY THIS PROVIDER, AS WELL AS YOUR RIGHTS REGARDING YOUR PHI. YOUR PHI INCLUDES INFORMATION WHICH RELATES TO YOUR PAST, PRESENT OR FUTURE HEALTH, TREATMENT OR PAYMENT FOR HEALTH CARE SERVICES.
1. LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
The Health Insurance Portability and Accountability Act (HIPPA) requires me to:
Keep your medical information private.
Give you this notice describing my legal duties, privacy practices and your rights regarding your medical information.
Follow the terms of the current notice.
I have the right to: Change my privacy practices and terms of this notice at any time, provided that the changes are permitted by law.
Notice of Change to Privacy Practices: Before an important change is made in my privacy practices, I will change this notice and make the new notice available upon request.
2. USE AND DISCLOSURE OF YOUR PHI
The following section describes different ways that your PHI may be used or disclosed. For some of these uses or disclosures, I will need your prior authorization; for others, I do not. I will not disclose your PHI for any purpose not listed below without your specific written authorization. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I haven’t taken any action in reliance on such authorization).
Uses and Disclosures Relating to Treatment, Payment or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:
FOR TREATMENT: I may disclose your PHI to other licensed health care providers who provide you with health care services or are involved in your care. For example, if you’re being treated by a psychiatrist. I may disclose your PHI to your psychiatrist in order to coordinate your care.
FOR PAYMENT: I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. I may also provide PHI to my business associates, such as my billing company, Comprehensive Billing Services, and others that process my health care claims.
FOR HEALTH CARE OPERATIONS: I may use and disclose your PHI to operate my practice.
ADDITIONAL USES AND DISCLOSURES that do not require consent:
When disclosure is required by federal, state or local law, judicial or administrative proceedings or law enforcement. For example, I may make a disclosure to applicable officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding.
For public health activities. As required by law, I may disclose your PHI to public health or legal authorities charged with preventing, controlling or responding to disease, injury, disability and/or death including child abuse and neglect.
For health oversight activities. For example, I may have to report information to assist the government when it conducts an investigation or inspection of a health provider or organization.
To avoid harm.
To prevent a serious threat to your own health or safety or the health or safety of others.
For workers’ compensation purpose. I may provide PHI in order to comply with workers’ compensation laws.
Appointment reminders and health related benefits or services. I may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits I offer.
3. YOUR INDIVIDUAL RIGHTS REGARDING YOUR PHI
The Right to Choose How I Send PHI to You. You have the right to ask that I send information to you at an alternate address or by alternate means (for example, e-mail instead of regular mail). I will agree to your request so long as it is reasonable for me to do so.
The Right to See and Get Copies of Your PHI. In most cases you have the right to get copies of your PHI, but you must make the request in writing. However, certain types of PHI will not be made available for inspection and copying. This includes psychotherapy notes or PHI collected in connection with a legal proceeding. I will respond to you within 10 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed. Instead of providing the PHI you requested, I may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
The Right to Get a List of the Disclosures I have Made. You have the right to get a list of instances in which I have disclosed your PHI. The list will not include uses or disclosures that you have already consented to such as those named for treatment, payment, or health care operations directly to you, or to your family. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel or disclosures made before June 1, 2008.
The right to ask that I limit how I use and disclose your PHI. I will consider your request, but I am not legally required to accept it. If I accept your request, I will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that I am ” legally” required or allowed to make.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. I will respond within 30 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (a) Correct and complete, (b) not created by me, (c) not allowed to be disclosed, and/or (d) not a part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request, I will make the change to your PHI, tell you that I have done it and tell others that need to know about the change to your PHI.
4. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES.
If you have any questions about this notice or any complaints about my privacy practices or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services please contact your provider, Family Christian Counseling Center of Phoenix. There will not be any retaliation for filing a complaint.
EFFECTIVE DATE OF THIS NOTICE. This notice went into effect on November 1st, 2010.