WHO WILL FOLLOW THIS NOTICE

This notice describes the information privacy practices followed by our employees, staff and other office personnel.

YOUR MENTAL HEALTH/HEALTH INFORMATION:

This notice applies to the information and records we have about you and the mental health/health care and services you receive at this office. Your mental health/health information may include information created and received by this office, may be in the form of written or electronic records or spoken words, and may include information about your mental health/health history, mental health/health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of mental health/health related information.
We are required by law to give you this notice. It tells you: 1) about the ways in which we may use and disclose mental health/health information about you and 2) describes your rights and our obligations regarding the use and disclosure of that information.

HOW WE MAY USE AND DISCLOSE MENTAL HEALTH/HEALTH INFORMATION ABOUT YOU:

We may use and disclose mental health/health information for the following purposes:

• For Treatment. We may use mental health/health information about you to provide you with clinical treatment or services. We may disclose mental health/health information about you to doctors, nurses, technicians, office staff, or other personnel who are involved in taking care of you and your mental health/health.
  For example, your doctor may be treating you for an Attention Deficit and may need to know if you have other health problems that could complicate your treatment. The doctor may use your clinical history to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate care for you.
  Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, or scheduling lab work or consultations. Family members and other mental health/health care providers may be part of your clinical care outside this office and may require information about you that we have.


• For Payment. We may use and disclose mental health/health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company, or a third party.
  For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also 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 treatment.


• For Mental health/health Care Operations. We may use and disclose mental health/health information about you in order to run the office and make sure that you and our other patients receive quality care.
  For example, we may use your mental health/health information to evaluate the performance of our staff in caring for you. We may also use mental health/health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.
  We may also disclose your mental health/health information to health plans that provide you insurance coverage and other mental health/health care providers that care for you. Our disclosures of your mental health/health information to plans and other providers may be for the purpose of helping these plans and providers improve care, reduce cost, coordinate and manage mental health/health care and services, train staff, and comply with the law.


• Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or clinical care at the office.


• Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.


• Mental Health/Health-Related Products and Services. We may tell you about mental health/health-related products or services that may be of interest to you.
  Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive information about treatment alternatives or mental health/health- related products and services. If you advise us in writing (at the address listed at the top of this Notice) that you do not wish to receive such communications, we will not contact you.
  Federal and State law require your written consent to release mental health/health information. The Consent will specify who is to receive the information, the purpose of the release of information, and a time period after which the Consent will terminate. You may modify or revoke a Consent at any time. However, if we are unable to fulfill our requirements related to treatment, payment or mental health/health care operations, we may choose to discontinue providing you with mental health/health care treatment and services.)

SPECIAL SITUATIONS

We may use or disclose mental health/health information about you for the following purposes, subject to all applicable legal requirements and limitations:

• To Avert a Serious Threat to Mental Health/Health or Safety. We may use and disclose mental health/health information about you when necessary to prevent a serious threat to your mental health/health and safety, or the mental health/health and safety of the public or another person.
  
• Required By Law. We will disclose mental health/health information about you when required to do so by federal, state or local law.


• Research. We may use and disclose mental health/health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the office.


• 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, we may be required by military command or other government authorities to release mental health/health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.


• Workers' Compensation. We may release mental health/health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.


• Public Health Risks. We may disclose mental health/health information about you for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.


• Mental Health/Health Oversight Activities. We may disclose mental health/health information to a mental health/health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the mental health/health care system, government programs, and compliance with civil rights laws.


• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose mental health/health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose mental health/health information about you in response to a subpoena.


• Law Enforcement. We may release mental health/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.


• Information Not Personally Identifiable. We may use or disclose mental health/health information about you in a way that does not personally identify you or reveal who you are.


• Family and Friends. We may disclose mental health/health information about you to your family members or friends if we obtain your verbal/written agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose mental health/health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal mental health/health information to an individual when you bring that individual with you into the room during treatment or while treatment is discussed.
  In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member is in your best interest. In that situation, we will disclose only mental health/health information relevant to the person's involvement in your care (For example, we may inform the person who accompanied you to the office updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf, for example, to pick up prescriptions.)

OTHER USES AND DISCLOSURES OF MENTAL HEALTH/HEALTH INFORMATION

We will not use or disclose your mental health/health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose mental health/health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

In some instances, we may need specific, written authorization from you in order to disclose certain types of specially protected information such as HIV, substance abuse, mental health/health, and genetic testing information.

YOUR RIGHTS REGARDING MENTAL HEALTH/HEALTH INFORMATION ABOUT YOU

You have the following rights regarding mental health/health information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and request a copy of your mental health/health information, such as clinical and billing records, that we keep and use to make decisions about your care. You must submit a written request to our clinic coordinator in order to inspect and/or request a copy of records of your mental health/health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other associated supplies.

We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied copies of or access to mental health/health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed mental health/health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
• Right to Amend. If you believe mental health/health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.
  To request an amendment, complete and submit a CLINICAL RECORD AMENDMENT/CORRECTION request to our clinic coordinator.
  We 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, we may deny your request if you ask us to amend information that:


• We did not create, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the mental health/health information that we 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 we made of clinical information about you for purposes other than treatment, payment, mental health/health care operations, and a limited number of special circumstances involving national security, correctional institutions, and law enforcement. The list will also exclude any disclosures we have made based on your written authorization.

To obtain this list, you must submit your request in writing to our clinic coordinator. It must state a time period, which may not be longer than six years, and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.


• Right to Request Restrictions. You have the right to request a restriction or limitation on the mental health/health information we use or disclose about you for treatment, payment, or mental health/health care operations. You also have the right to request a limit on the mental health/health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION to our clinic coordinator, Mindy Ranik, in writing.


• Right to Request Confidential Communications. You have the right to request that we communicate with you about clinical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may complete and submit a REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to our clinic coordinator, Mindy Ranik, in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.


• Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.
  To obtain such a copy, contact our clinic coordinator.

CHANGES TO THIS NOTICE

We reserve the right to change this notice, and to make the revised or changed notice effective for clinical information we already have about you, as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the bottom right hand corner. You are entitled to a copy of this notice currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a written complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, please send it in care of our clinic coordinator, Mindy Ranik. You will not be penalized for filing a complaint.

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