This notice describes how information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
YOUR HEALTH INFORMATION
This notice applies to the information and records my office has about your health, health status, and the counseling and care services you have received. This may include information created by me through the course of therapy; it may be in the form of written or electronic records or spoken words, and it may include information about your health history, health status, symptoms, counseling, evaluations, test results, use of medications as prescribed by others, diagnoses, treatments, procedures, and related billing activity and/or similar types of health-related information.
I am required by the Health Insurance Privacy and Portability Act (HIPPA) to give you this notice in either a printed or electronic format. It will tell you about the ways in which my office may use and disclose health information about you and it will describe your rights and my obligations regarding the use and disclosure of that information.
HOW YOUR HEALTH INFORMATION MAY BE USED OR DISCLOSED
My office may use and disclose health information for the following purposes:
For treatment: With your written consent my office may release information to your primary care physician and /or other treating physicians, therapists, counselors, care givers, office staff or other personnel who are involved in taking care of you and your health.
For example, your primary care provider may be treating you for a health condition and may need to know if your have issues or problems that could complicate your treatment. Your primary care provider may use this information to decide what treatment is best for you. I may ask to consult with your doctor or another clinician in the field of our practice to assist us in a choice of treatment that would be best for you. This will not happen without a written consent from you.
For payment: With your written consent my office may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from an insurance company or a third party payer.
For example, my office may need to give your health plan information about a service you received so your health plan will pay for the service or reimburse you for the service. I may also need to tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment. Additional information can be found on the “Using Insurance” form; insurance billing will not happen without written consent from you.
Appointment Reminders/Cancellations: I may contact you by phone to remind you that you have an appointment, to reschedule an appointment we already have, or to cancel an appointment that has been pre-scheduled. If you have indicated “no message” for a particular number, a message will not be left.
My office may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations
To Avert a Serious Threat to Health or Safety: I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
As Required By Law: I will disclose health information about you when required to do so by federal, state or local law, subject to all applicable legal requirements and limitations.
For Military, Veterans, National Security and Intelligence: If you are or were a member of the armed forces, or part of the national security or intelligence communities, I may be required by military command or other government authorities to release health information about you. I may also be required to release information about foreign military personnel to the appropriate foreign military authority.
For Workers’ Compensation: My office does not routinely work with workers’ compensation claims. If, however, you are referred for a workers compensation issue, my office may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
For Public Health Risks: My office may disclose health information about you for public health reasons in order to prevent suspected abuse or neglect or non-accidental physical injuries to yourself or another person.
For Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, my office may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, I may also disclose health information about you in response to a subpoena or in the instance where you have provided a signed consent.
For Law Enforcement: My office may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements and limitations.
For Coroners, Medical Examiners and Funeral Directors: My office may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to help determine the cause of death.
As Information Not Personally Identifiable: I may use or disclose health information about you in a way that does not personally identify you or reveal who you are. This may include discussion of your care in peer supervision or case consultation with another provider.
For Assignment to Collections for Non-payment of Account: My office may release health record information to a collection agency if your account is past due for more than 180 days or upon notice of such action.
For Family and Friends: My office may disclose health information about you to your family members or friends if your verbal agreement or your written authorization to do so is provided. I may also disclose information to your family or friends if I can infer from circumstances or based on professional judgment that you would not object.
For example, I will assume you agree to limited disclosure of information to your spouse or partner when you bring them with you to a counseling session and have not requested in writing that any form of disclosures cannot be made.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
My office will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written consent. If you give written consent to use or disclose health information about you, you may revoke that at any time. If you revoke your consent I will no longer use or disclose information about you; bear in mind, however, that I cannot take back any uses or disclosures already made with your permission.
I will need specific, written authorization from you in order to disclose certain types of specially-protected information such as HIV status, substance abuse, mental health, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information I maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy your health information, such as mental health and billing records, that I keep and use to make decisions about your care. You must schedule an appointment to inspect and/or copy records of your health information. If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other associated supplies.
I may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies of or access to information that I keep about you, you may ask for my decision to be reviewed. If the law gives you a right to have the denial reviewed, a licensed health care professional will be selected to review your request and my decision. The person conducting the review will not be otherwise associated with my office and I will comply with the outcome of the review.
Right to Amend: If you believe health information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment as long as my office generated the information, keeps and or stores it.
I may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask us to amend information that:
- My office did not create
- Is not part of the information that I keep
- You would not be permitted to inspect and copy
- Is accurate and complete
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures I have made of information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement, all of which have been previously listed in this notice. The list will also exclude any disclosures I have made based on your written authorization.
To obtain this list, you must submit your request in writing to the address at the top of this notice.
Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, I may charge you for the costs of providing the list. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the information I disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. Requests for Restrictions must be made in writing and specified on the specific Authorization form. I am not required to agree to your request. If I do agree, my office will comply with your request unless the information is needed to provide you emergency treatment or I am required by law to use or disclose the information.
Right to Request Confidential Communications: You have the right to request that I communicate with you about matters in a certain way or at a certain location. For example, you can ask that I only contact you at work by phone or by mail. Confidential Communication requests may be made on the “Necessary Information” form and/or amended during any therapy session or phone contact.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. Please ask.
DISCLOSURE BY ELECTRONIC MEANS
My office has specific policies about disclosure of your health care information by electronic means:
For Billing and Collections: My office uses a professional management service to send insurance billing either electronically or through the US Mail depending on availability of electronic receipt by the insurance carrier. The same service also prepares and sends account statements to clients who have balances outstanding.
For Transmission by Fax Machine: My office will send protected health care information via facsimile if required by the insurance carrier. If alternative optins, including post through the US Mail, are offered, my office will prefer the alternative option over facsimile unless such use would facilitate your care.
For Transmission by E-Mail: My office does send protected health care information by email if such documents can be password protected and/or sent through an encryption program to the receiver. My office prefers alternative means of sending this information including general post through the US Mail.
CHANGES TO THIS NOTICE
My office reserves the right to change this notice, and to make the revised or changed notice effective from information we already have about you as well as any information we receive in the future. I will post the current notice on my web page and will have paper copies available at my office locations. You are entitled to a copy of the notice currently in effect.
If you believe your privacy rights have been violated, please talk with me as soon as the concern is experienced. If discussion does not resolve your concern of if you feel that civil or criminal damages have occurred, you may file a complaint with the Secretary of the Department of Health and Human Services, with the Oregon State Board of Clinical Social Workers, or with the American Board of Examiners in Clinical Social Work. My Oregon license number is 2226 and my Board Certification number is 27765.
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