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. State and federal law protects the confidentiality of this information. “Protected health information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.”
Your Rights Regarding Your PHI You have the following rights regarding PHI I maintain about you:
Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and copy PHI that may be used to make decisions about your care. I may charge a reasonable cost-based fee for copies. Please note that disclosure of couple or family records, or the fact of counseling, require signed release from all adult patients.
Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. You have the right to write a statement of disagreement if a requested amendment is denied.
Right to Accounting of Disclosures. You have the right to request a copy of the required accounting of disclosures that I make of your PHI.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or of your PHI for treatment, payment or health care operations. I am not required to agree to your request.
Right to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. I will accommodate reasonable requests and will not ask why you are making the request.
Right to a Copy of this Notice. You have the right to a paper copy of this notice.
Right of Complaint. You have the right to file a complaint in writing with me or with the Secretary of Health and Human Services if you believe I have violated your privacy rights. I will not retaliate against you for filing a complaint.
Right to Opt Out. In accordance with federal guidelines, you have the right to not receive marketing or fundraising communications.
Right of Cash Payments. If you pay by cash, you have the right to request non disclosure of PHI to your health care insurer.
Right to Authorize. You have the right to authorize the sale of your PHI, your involvement with research, and uses and disclosures of psychotherapy notes in accord with WA state law.
Right to Notification of Breach. In the event of a breach of unsecured PHI, we are required by law to notify you.
My Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
Treatment. Your PHI may be used and disclosed by me for purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care services.
Payment. I will not use your PHI to obtain payment for your health care services without your written 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. Healthcare Operations. I may use or disclose, as needed, your PHI in order to support the business activities of my professional practice. Such disclosures could be to others for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist in the delivery of health care, provided I have a written contract requiring the recipient(s) to safeguard the privacy of your PHI. I may also contact you to remind you of your appointments, inform you of treatment alternatives and/or health-related products or services that may be of interest to you.
Other Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples are public health reports and law enforcement reports. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Health Oversight. I may disclose PHI to a health oversight agency for activities authorized by law, such as professional licensure. Oversight agencies also include government agencies and organizations that provide financial assistance to me (such as third-party payers).
Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information I disclose is limited to only the information which is necessary to make the initial mandated report. I may disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death. Threat to Health or Safety. I may disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety to the public or another person.
Criminal Activity on My Business Premises/Against Me and My Staff. I may disclose your PHI to law enforcement officials if you have committed a crime on my premises or against me or my staff.
Compulsory Process. I will disclose your PHI if a court of competent jurisdiction issues an appropriate order. I will disclose your PHI if you and I have each been notified in writing at least fourteen days in advance of a subpoena or other legal demand, and no protective order has been obtained, and I have satisfactory assurances that you have received notice of an opportunity to have limited or quashed the discovery demand.
Uses and Disclosures of PHI with Your Written Authorization Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization in writing at any time, unless I have taken an action in reliance on the authorization of the use or disclosure you permitted, such as providing you with health care services for which I must submit subsequent claim(s) for payment.
This Notice This Notice of Privacy Practices describes how I may use and disclose your protected health information
(“PHI”) in accordance with all applicable law. 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 my Notice of Privacy Practices at any time. I will make available a revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.
Complaints If you believe I have violated your privacy rights, you may file a complaint in writing to me. I will not retaliate against you for filing a complaint. You may also file a complaint with the U.S. Secretary of Health and Human Services.