Notice of Privacy Practices and HIPAA
(Health Insurance Portability and Accountability Act)
Please read the information below as it pertains to your rights regarding your protected health information (PHI). Please review the information below and by signing the, “Privacy Practices,” form you convey your understanding of this document. If you have any questions about this notice please contact Kristen C. Dew, LMFT at the information listed at the bottom of this document.
Please note that this document is required by law and describes ways that your information is used and accessed. I am required by law to maintain the privacy and confidentiality of your PHI and to provide you with a notice of privacy practices. I have summarized the information to help make it more understandable. If any changes are made to this document I will provide an updated notice.
I always prefer to obtain an authorization to release or obtain information signed by you in order to release information; however, by law I can use and disclose your PHI in some cases outlined below. I will always limit the amount of PHI when able to dependent on the information specifically related to the request.
I can use and disclose your PHI without your authorization for the following reasons:
- To obtain payment for your treatment: I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I provided to you.
- For health care operations: I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. I may also need to disclose PHI to my attorney to obtain advice about complying with applicable laws.
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For mandated reporting and public health activities including reported suspected child, elder or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- For health oversight activities including audits and investigations.
- For judicial and administrative proceedings and if subpoenaed.
- For law enforcement purposes including reporting crimes occurring on these premises.
- To coroners or medical examiners when such individuals are performing duties authorized by law.
- For worker’s compensation purposes: I may provide your PHI in order to comply with worker’s compensation laws.
- For your treatment: I may consult with a supervisor on all cases in order to provide quality treatment.
- Family/Partner Involvement in Care: I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent harm.
Certain Uses and Disclosures of PHI Which Require Your Authorization:
- Psychotherapy Notes: I keep a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment. There may be reasonable cost-based fees involved with copying the record or preparing the summary. I do not release psychotherapy notes without explicit client permission. In the case of court subpoena please be aware that psychotherapy notes may be confiscated.
- Marketing: I will not use or disclose your PHI for marketing purposes.
- Sale of PHI: I will not sell your PHI in the regular course of my business.
- Appointment reminders and health related benefits or services: I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives or other health care services/benefits that I may offer.
- For training or teaching purposes PHI will only be disclosed with your explicit authorization.
- You have the right to obtain a paper copy of your medical records. Upon your written request, I will provide a copy or summary of your health information. This may take up to 30 days and a reasonable fee may be charged.
- You can ask to revise your health information at any time by written request. I reserve the right to refuse your request but will provide a written rationale as to why tour request was denied within 30 days.
- You can ask to be contacted by this provider in a certain way (home phone, cell phone, email, etc.) and I will comply with most reasonable requests.
- You can ask this provider to limit or not share certain information for treatment, payment, or operations. I will comply with all reasonable requests unless a law exists requiring me to share the information.
- You can ask who I have shared your information with, what information I have shared, and why I have shared the information. I will include all disclosures except for those related to treatment, payment, health care operations, and certain other disclosures.
- You can ask for a copy of this notice at any time.
- You have the right to obtain someone else to act as medical power of attorney. I will make sure the person has this authority before proceeding.
- You have the right to decide and authorize this provider to share your PHI with family, friends, other medical providers, or others whom you deem fit.
- You have the right to file a complaint if you feel I have violated your rights by contacting Kristen C. Dew, LMFT (privacy officer) at the information at the end of this form, or by filing a complaint with the U.S. Department of Health at the following address: 200 Independence Ave. S.W. Washington, DC 20201; by calling 1-877-696-6775; or by visiting hhs.gov/ocr/privacy/hipaa/complaints/ .
The opportunity to consent may be obtained verbally, and signed retroactively, in emergency situations.
Kristen C. Dew, LMFT
755 Main St.
Building 8, Suite C, Office #5