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 review and retain a copy for your records.
I am required by law to maintain the privacy of your protected health information and to provide you with this notice, which explains our legal duties and privacy practices with respect to your protected health care information. I must abide by the terms set forth in this notice. However, I reserve the right to change the terms of this notice and make new notice provisions effective for all protected health information.
1. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I 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:
• PHI : refers to information in your health record that could identify you.
• Treatment, Payment and Health Care Operations: – Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health professional. – Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. – Healthcare Operations are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. I may also disclose your PHI to third-party business associates who perform certain activities for me (e.g. billing services).
• Use: Activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• Disclosure: Activities outside of my office such as releasing, transferring, or providing access to information about you to other parties.
2. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, or 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 I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization prior to releasing your Progress Notes. “Progress Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session.
You may revoke all such authorizations (of PHI or Progress Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
I will also obtain an authorization from you before using or disclosing:
• PHI in a way that is not described in this Notice.
3. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
• Serious Threat to Health or Safety : If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If I believe there is an imminent risk that you will inflict serious harm on yourself, I may disclose information in order to protect you (e.g. to initiate hospitalization procedures).
• Child Abuse : I am required to report PHI to the appropriate authorities when I have reasonable grounds to believe that a minor is or has been the victim of neglect or physical and/or sexual abuse.
• Adult and Domestic Abuse : If I have the responsibility for the care of an incapacitated or vulnerable adult, I am required to disclose PHI when I have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult’s property has occurred.
• Health Oversight Activities : If the Arizona Board of Behavioral Health Examiners is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena from the Board.
• Judicial and Administrative Proceedings : If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without a court order or the written authorization of you or your legally appointed representative. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
• Worker’s Compensation : I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
• When the use and disclosure without your consent or authorization is allowed under other 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.
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.
4. Your Rights
You have the right to:
– Get a copy of your paper or electronic medical record: You can ask to see or get a copy of your health records and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
– Correct your paper or electronic medical record: You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
– Request confidential communication: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
– Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
– Right to an Accounting : You generally have the right to receive an accounting of disclosures of PHI, except for: (1) disclosures made to you; (2) disclosures for treatment, payment, or health care operations; (3) incidents to a use or disclosure set forth in this notice; (4) disclosures made to law enforcement officials; or (5) information used as part of a limited data set, that occurred 6 years or more from the date of your request. Your request must be made in writing and must state the time period for the requested information. We may charge you a fee for your request. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred. On your request, I will discuss with you the details of the accounting process.
– Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We 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.
– File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us using the information on page 2. 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 Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
5. Our Responsibilities
– We are required by law to maintain the privacy and security of your protected health information.
– We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
– We must follow the duties and privacy practices described in this notice and give you a copy of it.
– We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
6. Contact Information
If you have any questions about this notice, please contact:
Linda Ruvalcaba, MA, LPC
Empieza Aquí Counseling
480-582-1870
linda@empiezaaqui.com
Effective Date: September 9, 2019
