Effective April 14, 2003, and revised Effective September 23, 2013
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
When this Notice refers to “we” or “us,” it is referring to Family Counseling Center LLC. It is also referring to contracted providers, and other direct and indirect services.
This Notice describes how we will use and disclose your health information. The policies outlined in this Notice apply to all of your health information generated by Family Counseling Center LLC, whether recorded in your mental health record, invoices, payment forms, or other ways. These policies also apply to the health information gathered from other organizations by any health care professional, employee or volunteer who participates in your care.
Uses and Disclosures of Your Health Information
- In some circumstances we are permitted or required to use or disclose your health information without obtaining your prior authorization and without offering you the opportunity to object. These circumstances include:
- Uses or disclosures relating to treatment, payment and health care operations:
- Treatment. We may use and/or disclose your health information to provide, or to allow others to provide, treatment to you. An example would be if your primary care physician discloses your health information to another doctor for a consultation. Also, we may contact you with appointment reminders or information about treatment options or other health-related benefits and services that may be of interest to you.
- Payment. We may use and/or disclose your health information for the purpose of allowing us, as well as other organizations, to secure payment for the health care services provided to you. For example, we may inform your health insurance company of your diagnosis and treatment in order to assist the insurer in processing our claim for the health care services provided to you.
- Health Care Operations. We may use and/or disclose your information for the purposes of our day-to-day operations and functions. We may also disclose your information to another covered entity (health care provider, health plan or health care clearinghouse) to allow it to perform its day-to-day functions, but only to the extent that we both have a relationship with you. For example, we may compile your health information, along with that of other patients, in order to allow a team of our health care professionals to review that information and make suggestions concerning how to improve the quality of care provided.
- Other Allowable Uses of Your Health Information
We may also participate in organized health care arrangements with other providers and facilities. If we do, we may use, or disclose to other covered entities also participating in the organized health care arrangements, your health information for any health care operations activities of the organized health care arrangements.
- Business Associates; there are some services provided to our office through contracts with business associates. Examples include outside attorneys, copy or shredding services. When these services are contracted, we may disclose your health information so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
- As required by law, we will disclose health information about you when required by federal, state or local law.
- For public health purposes; we may disclose health information about you for public health purposes, including: prevention or control of disease, injury or disability, reporting child abuse or neglect; notifying the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- To disclose information about victims of abuse, neglect, or domestic violence as required by law;
- For health oversight activities, such as audits or civil, administrative or criminal investigations;
- For judicial or administrative proceedings; we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you 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 notify you about the request or obtain an order protecting the information requested.
- For law enforcement purposes; we may disclose health information when requested by a law enforcement official: in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement; about a death we believe may be the result of criminal conduct; about criminal conduct at the office; and in emergency circumstances to report a crime; the location of the crime or victims; or to identify, description or location of the person who committed the crime.
- To avert a serious threat to health or safety;
- For specialized governmental functions, such as military, national security, criminal corrections, or public benefit purposes; and
- For workers’ compensation purposes, as permitted by law.
- Military and Veterans; if you are a member of the armed forces, we may disclose health information about to you to prevent a serious threat to your health and safety or the health and safety of the public or another person. We would do this only to help prevent the threat.
- We may also use or disclose your health information in the following circumstances. However, except in emergency situations, we will inform you of our intended action prior to making any such disclosures and will, at that time, offer you the opportunity to object.
- Notifications. We may disclose to your relatives or close personal friends any health information that is directly related to that person’s involvement in the provision of, or payment for, your care. We may also use and disclose your health information for the purpose of locating and notifying your relatives or close personal friends of your location, general condition or death, and to organizations that are involved in those tasks during disaster situations.
- The following uses and disclosures of your health information require your written authorization:
- Uses and disclosures of psychotherapy notes except:
- To carry out the following treatment, payment, or health care operations: Use by the originator of the psychotherapy notes for treatment; use or disclosure by us for our own training programs; or use or disclosure by us to defend ourselves in a legal action or other proceeding brought by you;
- Uses and disclosures to the federal Secretary of the Department of Health and Human Services required by the Secretary to investigate or determine our compliance with federal privacy regulations; and
- Uses and disclosures required by law or permitted with respect to the following: health care oversight of the originator of the psychotherapy notes; about decedents to coroners and medical examiners; or necessary to prevent or lessen a serious and imminent threat to health or safety;
- Uses and disclosures of psychotherapy notes except:
- Uses or disclosures relating to treatment, payment and health care operations:
Except as described in this Notice, uses and disclosures of your health information will be made only with your written authorization. Except as allowed by Federal or State laws or rules, any information released from mental health records and any drug or alcohol treatment records will require your written authorization. You may revoke your authorization at any time, in writing, unless we have taken action based on your prior authorization, or if you signed the authorization as a condition of obtaining insurance coverage.
- To Request Restrictions. You have the right to request restrictions on the use and disclosure of your health information for treatment, payment or health care operations purposes or notification purposes. We are not required to agree to your request unless your request is to restrict disclosure to a health plan that we would make for payment or healthcare operations purposes, and it is not required by law, and the information pertains to an item or services paid for in full by you or someone on your behalf other than the health plan. If we do agree to a restriction, we will abide by that restriction unless you are in need of emergency treatment and the restricted information is needed to provide that emergency treatment. To request a restriction, submit a written request to the Contact listed on the final page of this Notice.
- To Limit Communications. You have the right to receive confidential communications about your own health information by alternative means or at alternative locations. This means that you may, for example, designate that we contact you only at work rather than home. To request communications via alternative means or at alternative locations, you must submit a written request to the Contact listed on the final page of this Notice. All reasonable requests will be granted.
- To Access and Copy Health Information. You have the right to inspect and copy any health information about you other than information compiled in anticipation of or for use in civil, criminal or administrative proceeding. To arrange for access to your records, or to receive a copy of your records, you must submit a written request to the Contact listed on the last page of this Notice. If you request copies, you will be charged our regular fee for copying and mailing the requested information. Despite your general right to access your Protected Health Information, access may be denied in some limited circumstances. For example, access may be denied if you are an inmate at a correctional institution or if you are a participant in a research program that is still in progress. Access may be denied if the federal Privacy Act applies. Access to information that was obtained from someone other than a health care provider under a promise of confidentiality can be denied if allowing you access would reasonably be likely to reveal the source of the information. The decision to deny access under these circumstances is final and not subject to review. In addition, access may be denied if (i) access to the information in question is reasonably likely to endanger the life and physical safety of you or anyone else, (ii) the information makes reference to another person and your access would reasonably be likely to cause harm to that person, or (iii) you are the personal representative of another individual and a licensed health care professional determines that your access to the information would cause substantial harm to the patient or another individual. If access is denied for these reasons, you have the right to have the decision reviewed by a health care professional who did not participate in the original decision. If access is ultimately denied, the reasons for that denial will be provided to you in writing.
- To Request Amendment. You may request that your health information be amended. Your request may be denied if the information in question: (i) was not created by us (unless you show that the original source of the information is no longer available to seek amendment from), (ii) is not part of our records, (iii) is not the type of information that would be available to you for inspection or copying, or (iv) is accurate and complete. If your request to amend your health information is denied, you may submit a written statement disagreeing with the denial, which we will keep on file and distribute with all future disclosures of the information to which it relates. Requests to amend health information must be submitted in writing to the Contact listed on the final page of this Notice.
- To an Accounting of Disclosures. You have the right to an accounting of any disclosures of your health information made during the six-year period prior to the date of your request. The accounting will include the date of each disclosure, the name of the entity or person who received the information and that person’s address (if known), and a brief description of the information disclosed and the purpose of the disclosure. However, the following disclosures will not be accounted for: (i) disclosures made for the purpose of carrying out treatment, payment or health care operations, (ii) disclosures made to you, (iii) disclosures of information made to persons involved in your care, or for the purpose of notifying your family or friends about your whereabouts, (iv) disclosures for national security or intelligence purposes, (v) disclosures to correctional institutions or law enforcement officials who had you in custody at the time of disclosure, (vi) disclosures that occurred prior to April 14, 2003, (vii) disclosures made pursuant to an authorization signed by you, (viii) disclosures that are part of a limited data set, (ix) disclosures that are incidental to another permissible use or disclosure, or (x) disclosures made to a health oversight agency or law enforcement official, but only if the agency or official asks us not to account to you for such disclosures and only for the limited period of time covered by that request. To request an accounting of disclosures, submit a written request to the Contact listed on the final page of this Notice.
- To a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request. You may obtain a copy of this Notice at our website, www.familycounselingcenterllc.com.
- We are required by law to maintain the privacy of your health information and to provide you with this Notice of our legal duties and privacy practices.
- We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and to make those changes applicable to all health information that we maintain. Any changes to this Notice will be posted on our website (if applicable) and at our office, and will be available from us upon request.
- We are required by law to notify you if there is a breach of any of your health information which was unsecured.
You can complain to us and to the federal Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To lodge a complaint with us, please file a written complaint with the Contact listed below. This Contact person will also provide you with more information about our privacy policies upon request. No action will be taken against you for filing a complaint.
Office Manager, Family Counseling Center, LLC