THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective November 1, 2021.
- MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality health care and to comply with certain legal requirements. For example, I may need to use, disclose, and/or share certain health information about you as necessary for treatment, payment of services provided, and health care operations. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you to other parties. I also describe your rights to the health information I keep regarding your health, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
- Make sure that protected health information that identifies you (“PHI”) is kept private and confidential.
- Give you this notice of my legal duties and privacy practices with respect to health information.
- Follow the terms of the notice that is currently in effect.
- I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website at CenterforEmbodiedHealing.com. Each time you register at New Moon Center for Embodied Healing for health services, you may receive a copy of the Notice in effect at the time.
- HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the following categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This, too, can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard., because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
- Psychotherapy Notes.I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization* unless the use or disclosure is:
For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
- Alcohol and Drug (i.e., Substance) Abuse. Alcohol and drug abuse information has special privacy protections. New Moon Center for Embodied Healing will not disclose any information identifying an individual as being a patient, or provide any health information relating to the patient’s substance abuse treatment, unless the patient first authorizes us in writing; to carry out treatment, payment, and operations; or, as otherwise required by law.
- Marketing Purposes.As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
- Sale of PHI.As a psychotherapist, I will not sell your PHI in the regular course of my business.
*Except as otherwise provided in this Notice, we will not use or disclose your medical information, unless you explicitly authorize New Moon Center for Embodied Healing (“us”) in writing to do so. Should you authorize us to use or disclose your medical information for such a purpose, you may always withdraw or revoke your permission at any time, which will become effective only after the date of your written withdrawal.
- CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- For health oversight activities, including, but not limited to: audits, investigations, inspections, and maintaining professional licensure.
- For judicial and administrative proceedings, including, but not limited to: responding to a court or administrative order, subpoena, discovery request, or other lawful request. My preference, however, is to obtain an Authorization from you before doing so.
- For federal, state, and local law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners, medical examiners, or funeral directors when such individuals are performing duties authorized by law.
- For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
- Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
- To military command authorities if you are a member of the armed forces or a member of a foreign military authority
- For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws. Your medical information regarding benefits for work-related injuries and illnesses may be released as appropriate.
- Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
- To carry out health care treatment, payment, and operations functions through business associates/affiliates. For example, to install a new computer system in the offices.
- CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or other third-parties. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
- YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
- The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
- The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
- The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within thirty (30) days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
- The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within sixty (60) days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
- The Right to Correct, Update, or Amend Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within sixty (60) days of receiving your request.
- The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. This Notice will also be posted electronically on our website at CenterforEmbodiedHealing.com
- In the unforeseen event of your therapist being unable to perform services, your records will be available to you via Kayla Schuster, LGPC. She can be reached at 240-622-9200. If, in the unforeseen event, Kayla Schuster is unable to perform services, records will be available via Vonda Dunn, LCPC. She can be reached at 301-730-4192.
If you believe your privacy rights have been violated, you may file a complaint with:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509 F, HHH Building
Washington, D.C. 20201
We will not penalize or retaliate against you in any way for making a complaint to the Department of Health and Human Services or any other applicable local, state, or federal governmental agencies.
In the highly unlikely event of a breach of your unsecured protected health information, we will notify you of the breach as soon as possible.
Please contact us by calling 240-622-9200 or emailing email@example.com if:
- You have any questions about this Notice;
- You would like a paper or electronic copy of this Notice;
- You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or,
- You wish to obtain a form to exercise your individual rights.
- If you believe your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to myself or your therapist.
You have specific rights under the Privacy Rule. New Moon Center for Embodied Healing will not retaliate against you for exercising your right to file a complaint.
January 1, 2022
This notice originally went into effect on February 1, 2020 and was updated November 1, 2021.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of New Moon Center for Embodied Healing’s “HIPAA Notice of Privacy Practices”.