THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Commitment to Your Privacy:
I am required by law to provide you with a notice that explains my privacy practices with regard to your medical information and how I may use and disclose your protected health information (PHI). In my psychotherapy practice, I will create records regarding you and our work together and services I provide to you. I am required by law to maintain the confidentiality of health information that identifies you. I am also required by law to provide you with this notice of my legal duties and the privacy practices that I maintain in my practice concerning your PHI. By federal and state law, I must follow the terms of the Notice of Privacy Practices that I have in effect at the time.
I realize that these laws are complicated, but I must provide you with the following important information:
- How I may use and disclose your PHI,
- Your privacy rights in your PHI,
- My obligations concerning the use and disclosure of your PHI.
- I am required by law to maintain the privacy and security of your protected health information.
- I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- I must follow the duties and privacy practices described in this notice and give you a copy of it.
- I will not use or share your information other than as described below unless you tell me in writing that I can. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
The terms of this notice apply to all records containing your PHI that are created or retained by my practice. I reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that my practice has created or maintained in the past, and for any of your records that I may create or maintain in the future. You may request a copy of the most current Notice at any time.
If you have questions about this Notice, please contact:
Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209, email@example.com
Uses and Disclosures of PHI:
The following categories describe the different ways in which I may use and disclose your PHI:
- Provision and Coordination of Services. I may use and disclose your PHI to provide, coordinate, or manage your mental health services. I may also disclose your health information to other health care providers who are working with you. For example, if you are seeing a psychiatrist, I can disclose your PHI to your psychiatrist to coordinate your care. Additionally, I may disclose your PHI to others who may assist in your care, such as your partner/s or other loved ones.
- Payment. I may use and disclose your PHI to bill and collect payment for the services I provide you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you.
- Health Care Operations. I may use and disclose your PHI to support and operate my practice. For example, I may use your PHI to review and evaluate your services or to evaluate my performance while working with you.
- Appointment Reminders. I may use and disclose your PHI to contact you as a reminder about scheduled appointments.
- Care Alternatives. I may use and disclose your PHI to tell you about or recommend possible alternative services or options that may be of interest to you.
- Others Involved in Your Care. I may use and disclose your PHI to a family member, a close friend, or any other person you identify that is involved in your mental health services or payment for services.
- As Required by Law. I may use and disclose your PHI when required to by federal, state, or local law.
Use and Disclosure of PHI in Special Circumstances:
The following describe unique scenarios in which I may use or disclose your PHI:
- Public Health Risk. I may use and disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
- Reporting child abuse or neglect,
- Reporting abuse or neglect of a vulnerable person, and,
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult client (including domestic violence); however, I will only disclose this information if you agree or if I am required or authorized by law to disclose this information.
- Health Oversight Activities. My practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or compliance with civil rights laws and the health care system in general.
- Lawsuits and Similar Proceedings. My practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. I also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if I have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
- Workers’ Compensation. My practice may release your PHI for workers’ compensation and similar programs.
Your Rights Regarding Your PHI:
Although your health record is the physical property of my practice because I compiled it, the information belongs to you. You have the right to:
- Confidential Communications. You have the right to request that I communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that I contact you at home, rather than work. You do not need to give a reason for your request.
- Requesting Restrictions. You have the right to request a restriction in my use or disclosure of your PHI for services, payment, or health care operations. Additionally, you have the right to request that I restrict my disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. I am not required to agree to your request; however, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in my use or disclosure of your PHI, you must make your request in writing to me at Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209. Your request must describe in a clear and concise fashion:
- The information you wish restricted,
- Whether you are requesting to limit my practice’s use, disclosure or both,
- To whom you want the limits to apply.
- Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209 in order to inspect and/or obtain a copy of your PHI. My practice will charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. My practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of the denial. Another licensed health care professional chosen by me will conduct reviews.
- Amendment. You may ask me to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by my practice. To request an amendment, your request must be made in writing and submitted to Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209. You must provide me with a reason that supports your request for amendment. My practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, I may deny your request if you ask me to amend information that is in my opinion: (a) accurate and complete; (b) not part of the PHI kept by my practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by my practice.
- Accounting of Disclosures. All of my clients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures my practice has made of your PHI for purposes not related to treatment, payment, or operations. Use of your PHI as part of the routine client care in my practice is not required to be documented. For example, when I use your information to file an insurance claim for payment. In order to obtain an accounting of disclosures, you must submit your request in writing to: Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before May 8, 2020. The first list you request within a 12-month period is free of charge, but my practice may charge you for additional lists within the same 12-month period. My practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
- Right to a Paper Copy of this Notice. You are entitled to receive a paper copy of my notice of privacy practices. You may ask me to give you a copy of this notice at any time. To obtain a paper copy of this notice, write me at: Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209.
- Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with my practice or with the Secretary of the Department of Health and Human Services. To file a complaint with my practice, contact me at: Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
- Right to Provide an Authorization for Other Uses and Disclosures. My practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to me regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, I will no longer use or disclose your PHI for the reasons described in the authorization. Please note: I am required to retain records of your care.
Privacy Officer Information:
If you have any questions regarding my notice of privacy policies, complaints about my privacy practices, or need information on how to file a complaint, please contact Lourdes Dolores Follins, Ph. D., 307 72nd Street, Suite 1E, Brooklyn, NY 11209, firstname.lastname@example.org