LEARNING SOLUTIONS 2 Main StreetFlorence, MA 01062-3500(413) 584-0265 ∙ Fax (413) email@example.com
(If child under 18)
NOTICE OF PRIVACY POLICIES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.
Please read it carefully!
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your PCP or another therapist.
Payment is when we obtain reimbursement for your healthcare. Examples of payment are when We disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and case coordination.
Use applies to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
We may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when We are asked for information for purposes outside of treatment, payment and health care operations, We will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your chart. These notes are given a greater degree of protection than PHI. It is PANR’s policy not to keep separate psychotherapy notes. All documentation we keep is a part of your clinical chart.
We will also obtain an authorization from you before using or disclosing PHI in a way that has not been described in this notice.
We will not use your PHI for marketing or sales purposes under any conditions.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
When the use and disclosure without your consent or authorization is allowed under sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law, this includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
Mental Health Clinician’s Duties:
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer: Duncan Laird at this office You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request
This notice will go into effect September 24, 2013. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will notify current clients of changes in person or by mail and closed client cases can, if interested, call and ask if our policies have changed and obtain a copy by mail or view one in our waiting area.
I understand and acknowledge the HIPAA regulations for Learning Solutions for Learning Success, Learning Solutions for Learning Success, LLC.
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