Notice of Privacy Practices
Jennifer Brown, L.L.C. Licensed Clinical Social Worker
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you, referred to as Protected Health Information (“PHI”). This includes information about your mental health and the treatment you receive from me. This Notice of Privacy Practices describes how that information may be disclosed and how you may access that information, in accordance with applicable laws.
I am required by law to protect the privacy of PHI and to provide you with this notice. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices at your request or upon your next appointment.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
I am permitted to use or disclose your PHI for treatment purposes, payment and health care operations without your written authorization under Federal regulations. Please understand that AT ALL TIMES, every effort is made to release as little information as is possible to conduct these services and maintain your privacy.
For Treatment. Your PHI may be disclosed for the purpose of providing, coordinating, or managing your mental health care treatment. This includes consultation with clinical supervisors or other consulting treatment providers, such as your psychiatrist/PCP if you are being prescribed medication.
For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your EAP/insurance company, or reviewing services provided to you to determine medical necessity. If you pay out of pocket, I will not disclose your information to your health plan unless you request for me to do so.
For Health Care Operations. In order for me to operate efficiently and in cooperation with applicable law and insurance requirements, it may be necessary for me to compile or disclose your PHI. For example, I may use your PHI if an insurance company decides to audit my practice in order to review my performance. I may share PHI with various third parties to perform operations such as billing.
I MAY use or disclose your health information for the following purposes under limited circumstances:
Child Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect or elder abuse or neglect.
Judicial and Administrative Proceedings. I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel or to family members directly involved in your treatment ONLY to prevent serious harm.
Law Enforcement. I may disclose PHI to a law enforcement official as required by law. An example of this would be reporting information related to a crime in an emergency.
Public Safety. I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If this occurs, the information will be disclosed only to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. An example of this would be the use and disclosure of psychotherapy notes which are separated from the rest of your medical record. I will not use your PHI for marketing purposes. I willl not sell your PHI.
YOUR RIGHTS REGARDING YOUR PHI
You have the right to:
- Right of Access to Review and Obtain. You have the right, which may be restricted in certain circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. This does not include my psychotherapy notes, which are maintained separately from the rest of your record. I may charge a reasonable, cost-based fee for copies or mailing fees. All requests must be written.
- Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask, in writing, to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy.
- Right to an Accounting of Disclosures. You have the right to request, in writing, an accounting of certain disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction on the use or disclosure of your PHI as provided by law. You must submit a written request. I am not required to agree to your request.
- Right to Request Confidential Communication. You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact.
- Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
- To exercise any of these rights, please submit your request in writing to the Privacy Officer :
Jennifer Brown, L.C.S.W., 2565 Thompson Bridge Road, Suite 207, Gainesville, GA 30501.
If you believe I have violated your privacy rights, you have the right to file a complaint in writing with the Privacy Officer: Jennifer Brown, L.C.S.W., 2565 Thompson Bridge Road, Suite 207, Gainesville, GA, 30501, or with the Secretary of Health and Human Services. I will not retaliate against you for filing a complaint.
The effective date of this Notice is January 1, 2017.