This notice describes how medical information about you may be used and is disclosed and how you can get access to this information. Please review this notice carefully.
Your mental health record contains personal information about you and your health. This information about you that may identify you and related to you past, present and future physical or mental health or condition and related health care services is referred to a as Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and additionally describes how to gain access 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 by law to abide by these terms. I reserve the right to change the terms of these 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 of any revised notices.
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating or managing your health care treatment and related services. This includes consultation with treatment team members such as couple therapists, family therapists or primary care doctors. I may disclose PHI to any other consultant only with your authorization.
For Payment: I may disclose PHI in order to receive payment for 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 purposes of collection.
For Health Care Operations : I may use or disclose you PHI as needed to support business activities including but not limited to quality assessment activities, licensing, or other activities such as billing or typing services provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For teaching or training 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. In addition, I must make disclosures to the Seceratary of the Department of Health and Human Services for purposes of investigating or determining my compliance with the Privacy Rule.
Without Authorization: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are:
Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board of the healt department)
Required by court order
Necessary to prevent of lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonable able to prevent or lessen the threat, including the target of the threat.
Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization which may be revoked.
You have the following rights regarding PHI that I maintain about you. The exercise any of the following rights, please submit a written request to me:
Right of Access to Inspect and Copy: You have the right which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. 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. There is a reasonable, cost-based fee for copies.
Right to amend: If you fell that the PHI I have about you is incorrect of incomplete, you may ask me to amend the information although I am not required to agree to the amendment.
Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one account in a 12 month period.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care options. I am not required to agree with your request
Right to a Copy of this Notice: You have a right to a copy of this notice.
If you believe that I have violated your privacy rights you may speak with me directly or file a complaint in writing with the Secretary of Health and Human Services at 200 Independence Ave., S.W., Washington, D.C. 20201 or by calling 202 619-0257. There will be no retaliation against you for filing a complaint
Effective date of this notice: January 1, 2010
Name_______________________________________________________
Date of Birth__________________________________________________
Social Security Number_________________________________________
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Privacy Practices for the therapy practice of Meryl Fingrutd, LISW. I understand that if I have any questions regarding the notice or my privacy rights that I will talk with Meryl Fingrutd.
______________________________________________________________________________
Signature Date
______________________________________________________________________________
Signature of Parent, Guardian or Personal Representative* Date
*If you are signing as a personal representative, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.)
_________________________________ refuses to acknowledge receipt