Notice of Privacy Practices
Your Information. Your Rights. My Responsibilities.
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.
When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.
Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. Ask me how to do this. I will provide a copy or a summary of your health information, usually within 10 days of your request. If it takes longer, I will notify you not later than 30 days with an explanation of the delay and when it will be available. I may charge a reasonable, cost-based fee.
Ask me to correct your medical record: You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. I may say “no” to your request, but I will tell you why in writing within 60 days.
Request confidential communications: You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will consent to all reasonable requests.
Ask me to limit what I use or share: You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get a list of those with whom I have shared information: You can ask for a list (accounting) of the times I have shared your health information for 6 years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice: You can download a paper copy of the BMBT Notice of Privacy Practices at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure that person has this authority and can act for you before I take any action.
File a complaint if you feel your rights are violated: You can complain if you feel I have violated your rights by contacting me using the information listed on this website. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave., S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.
For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.
In these cases, you have both the right and choice to tell me to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. Include your information in a hospital directory. If you are unable to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when need to lessen a serious and imminent threat to health or safety.
In these cases we NEVER share your information unless you give us written permission: Marketing purposes, fundraising efforts, sale of your information, most sharing of psychotherapy notes.
OUR USES AND DISCLOSURES
How do I typically use or share your health information? In the following ways:
Treat you: I can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run my practice: I can use and share your health information to run my practice, improve your care, and contact you when necessary. Example: I use health information about you to manage your treatment and services.
Bill for your services: I can use and share your health information to bill and get payment from health plans or other entities. Example: I give information about you to your health insurance plan so it will pay for your services.
How else can I use or share your health information? I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I have to meed many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues: I can share health information about you for certain situations such as: preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence preventing or reducing a serious threat to anyone’s health or safety.
Do research: I can use or share your information for health research. But if that happens, your identity will be masked and no one will be able to figure out that this information is about you!
Comply with the law: I will share information about you if state or federal laws require it, including with the Department of Health and Human Services. They will check to see if I am complying with federal privacy law.
Respond to organ and tissue donation requests: I can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director: I can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests: I can share health information about you in response to a court or administrative order, or in response to a subpoena.
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 here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
Psychological notes will be separated from the rest of your medical or mental health record.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.htlm.
Changes to the terms of this notice:
I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office or on this website.
Reviewed and approved by Joni Evans, LCPC, LMFT April 21, 17