Understanding Your Health Information and Your Rights

(effective date: April 14, 2003)

As part of your counseling here, a record will be made of each visit and any other important exchange of information on your behalf. This record may include your symptoms, diagnosis, treatment plan and other impressions. Your information is used by insurance companies to verify that the services billed for were actually provided. Although your health record belongs to the healthcare provider, you do have certain rights with regard to your health information.

Those rights include the following:

•     The right to expect that your information will be kept secure and used only for legitimate purposes.

•     The right to understand how your information may be used and disclosed.

•     The right to ask questions about any health privacy issue and get clear and prompt answers.

•     A limited right to know who has seen your health information and for what purpose.

•     A right to see, and to keep a copy of all your health records (except psychotherapy notes). Your request must be in writing and you may be charged a reasonable copying fee.

•     A right to ask for correction or inclusion of a statement of disagreement for anything in your records that you feel is in error. Your request must be in writing and include supporting documentation.

•     A right to authorize or refuse additional uses of your health information, such as for fundraising, marketing or research.

•     A right to request extra protections for health information you consider especially sensitive, and to request that I communicate with you by alternative means.

My Responsibilities:

I also have certain responsibilities. These include:

•     Maintaining the privacy of your record.

•     Providing you with a copy of this Notice.

•     Abiding by the terms of this Notice.

•     Notifying you if I am unable to agree to a requested amendment or restriction.

•      Accommodating reasonable requests you may have to communicate health information by alternative means.

If my information practices change, I may change this notice If so, the change will be effective for information gathered both before and after the effective date of such change.

Disclosures for Treatment, Payment and Healthcare Operations:

Your health information will not be used or disclosed without your authorization, except as described in this Notice. Your information may be used for treatment, payment and healthcare functions without your permission. However, if state law requires me to obtain written permission, I will do so.

I will use or disclose your health information for treatment. For instance, I may provide your physician or other healthcare provider with copies of reports that may help in determining your future treatment or coordinate treatment. You information may also be disclosed for payment purposes.

I will use or disclose your health information for payment. In order to bill your insurance company, your bill may contain information that identifies you, your diagnosis, procedures and dates and times of service. Your dates of services and charges may be disclosed for collection purposes as well.

I will use or disclose your information for healthcare operations and internal business practices.

Other Disclosures That May Be Made Without Your Authorization:

Family members, personal representatives or another person responsible for your care may be informed about your location and general condition and health information relevant to that person’s involvement in your care or payment related to your care.

Some services of my practice are provided through contractual arrangements with business associates, such as the front office staff, cleaning services, computer and accounting services. These business associates must use appropriate safeguards to protect your health information.

In Worker’s Compensation situations, I may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

When required or permitted by law, I may disclose your health information to public health or legal authorities responsible for preventing or controlling disease, injury or disability or performing other public health functions. In addition, I may disclose your health information in order to avert a serious threat to health or safety.

I may disclose your health information for military and veterans’ activities, national security and intelligence activities and similar special governmental functions, as required or permitted by law.

Some disclosures are required by law, These may include a valid subpoena, court order or other binding authority.

Your health information may be disclosed to appropriate health oversight agencies, public health authority or attorney involved in health oversight activities.

If you believe your privacy rights have been violated, you can file a complaint with me or with the Secretary of Health and Human Services. I will not retaliate against you for filing a complaint.