Notice of Privacy Practices Revised Effective Date 11/08/05
This notice provides information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient right with regard to the use and disclosure of your Protected health Information (PHI). In this Notice, we will call all of that protected health information “medical information.” 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. We will be happy to answer any of your questions.
HIPAA requires that we provide you with a copy of this Notice, and that we attempt to obtain your signature acknowledging receipt of this Notice.
How We May Use and Disclose Medical Information About You
We use and disclose medical information about you for a number of different purposes. Each of those purposes is described below.
We may use medical information about you to provide, coordinate or manage your health care and related services by both us and other health care providers. We may disclose medical information about you to doctors, nurses, hospitals and other health facilities who become involved in your care with your consent. We may consult with other health care providers within this practice concerning you and as part of the consultation share your medical information with them. We may refer you to another health care provider and as part of the referral, may share medical information about you with that provider with your consent. For example, we may conclude you need to receive services from a physician or therapist with a particular specialty. When we refer you to that physician or therapist, we also will contact that physician or therapist’s office and provide medical information about you to them so they have information they need to provide services for you.
For Payment (for in-person services only)
We may use and disclose medical information about you so we can be paid for the services we provide to you with your consent. This can include billing to you, your insurance company, or a third party payer. For example, we may need to give your insurance company information about the health care services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your medical condition and the health care you need to receive to obtain a determination if you are covered by that insurance or program.
For Health Care Operations
We may use and disclose medical information about you for our own health care operations. These are necessary for us to operate NDSBS and to maintain quality health care for our patients. For example, we may use medical information about you to review the services we provide and performance of our staff in caring for you. We may also use the information to study ways to more efficiently manage our organization, or we may need to share your information with people or companies who perform services for us, such as our lawyer or accountant, on an as needed basis.
How We Will Contact You
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate to you in a certain way or at a certain location, see “Right to Receive Confidential Communications.”
We may use and disclose medical information about you to contact you to remind you of an appointment you have with us.
We may use and disclose medical information about you to contact you about treatment alternatives that may be of interest to you.
Required or Allowed By Law
We may use or disclose medical information about you when we are required or allowed to do so by law.
Public Health Activities
We may disclose medical information about you for public health activities and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect.
Victims of Abuse or Neglect/Duty to Protect
We may disclose medical information to a government authority authorized by law to receive reports of abuse or neglect, or to other specified individuals/agencies, if we believe you are or another person is a victim or potential victim of abuse or neglect. This may involve a child under 18, a mentally retarded/developmentally disabled individual, or a senior adult. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you; or (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims.
Health Oversight Activities
We may disclose medical information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.
Judicial and Administrative Proceedings
We may disclose medical information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal.
Disclosures for Law Enforcement Purposes
We may disclose medical information about you to a law enforcement official for law enforcement purposes:
1. As required by law.
2. In response to a court, grand jury or administrative order, warrant or subpoena
3. To identify or locate a suspect, fugitive, material witness or missing person.
4. About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
5. About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
6. To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
7. About crimes that occur at our facility.
8. To report a crime in emergency circumstances.
We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
Mental Health or Chemical Dependency Records
If we receive health information about you from a health care provider, we will not re-disclose or otherwise reveal any mental health or chemical dependency records contained in that information, beyond the purpose of the disclosure to us, without first obtaining your written authorization, if that is required by law. There are certain other times when we may disclose information, including if you are a member of the armed forces, in certain instances involving National Security and Intelligence, or if you are an inmate.
Other Uses and Disclosures
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying your therapist in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Medical Information About You
You have the following rights with respect to medical information that we maintain about you.
Right to Request Restrictions
You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations.
To request a restriction, you may do so at any time. If you request a restriction, you should do so with your therapist and tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and , (c) to whom you want the limits to apply.
We are not required to agree to any requested restriction. However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.
Right to Receive Confidential Communications
You have the right to request that we communicate medical information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail, email or at work. We will not require you to tell us why you are asking for the confidential communication.
If you want to request confidential communication, you must do so in writing to your therapist. Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, when appropriate, require information from you concerning how payment will be handled. We also may require an alternate address or other method to contact you.
Right to Inspect and Copy
With a few very limited exceptions, you have the right to inspect and obtain a copy of medical information about you. You have an absolute right to all materials created by your treating therapist.
To inspect or copy medical information about you, you must submit your request in writing to your therapist. Your request should state specifically what medical information you want to inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing. You may be required to sign two authorization forms, one for psychotherapy notes and one for the rest of the records.
We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.
We may deny your request to inspect and copy medical information if the medical information involved is information compiled in anticipation of, or use in , a civil, criminal or administrative action or proceeding, i.e. that the information was not created for treatment purposes.
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.
Right to Amend
You have the right to ask us to amend medical information about you. You have this right for so long as the medical information is maintained by us.
To request an amendment, you must submit your request in writing to your therapist. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the medical information by appending or otherwise providing a link to the amendment.
We may deny your request to amend medical information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend medical information if we determine the information:
1. was not created by us, unless the person or entity that created the information is no longer available to act on the requested amendment;
2. is not a part of the medical information maintained by us;
3. would not be available for you to inspect or copy; OR
4. is not accurate and complete.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or summary of that information) with any subsequent disclosure of the medical information involved.
You also will have the right to complain about our denial of your request.
Right to an Accounting of Disclosures
You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting, including:
1. Disclosures to carry out treatment, payment and heath care options.
2. Disclosures of your medical information made to you.
3. Disclosures that are incident to another use or disclosure
4. Disclosures that you have authorized.
Under certain circumstances your right to an accounting of disclosures to a law enforcement official or health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures you must submit your request in writing to your therapist. Your request must state a time period for the disclosures. It may not be longer that six (6) years from the date we receive your request and may not include dates before April 14, 2003.
Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.
Right to Copy of This Notice
You have the right to obtain a paper copy of our Notice of Privacy Practices, upon request, even if you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time. To obtain a paper copy of this notice, contact your therapist.
We are required by law to maintain the privacy of medical information about you and to provide the individuals with notice or our legal duties and privacy practices with respect to medical information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.
Our Right to Change Notice of Privacy Practices
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the effective date of the new notice. We will provide you with a revised notice by mail or fax upon request.
Availability of Notice of Privacy Practices
At any time, you may obtain a paper copy of our current Notice of Privacy Practices.
Effective Date of Notice
The effective date of the notice will be stated on the first page of the notice.
You may complain to us and/or to the United States Secretary of Health and Human Services if you believe that we have violated your privacy rights.
To file a complaint with us, contact the Director of the practice at:
NDSBS / Directions Counseling Group, Inc.
6797 North High Street, Suite 350
Worthington, Ohio 43085
To file a complaint with the United States Secretary of Health and Human Services, write, call, or fax your complaint to:
Region V, Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Ph. (312) 886-2359
Fax (312) 886-1807
TDD (312) 353-5693
You will not be retaliated against for filing a complaint.
Questions and Information
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact your therapist or the Executive Director of NDSBS at (614) 888-9200.