NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Effective Date of this Notice: 2/25/2021
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
State and Federal Laws require that I share with you the following, concerning your protected health information or your PHI:
My obligation concerning the use and disclosure of your PHI.
How I may use and disclose your PHI.
Your privacy rights related to your PHI.
I provide counseling services under the business name, When Ready Counseling, LLC. Your privacy and confidentiality are of utmost importance to me. I am required by law to maintain the privacy and confidentiality of your personal health care information (PHI) and to provide you with this notice of my legal duties and privacy practices with respect to your protected health information. The terms of this notice apply to all records containing your PHI that are created or retained by When Ready Counseling, LLC. When I use or disclose this information, I am required to abide by the terms of this notice (or other notice in effect at the time of the use or disclosure).
Protected Health Information in connection with alcohol or drug services
42 CFR Part 2 protects your health information if you are applying for or receiving services (including diagnosis, treatment, or referral) for drug or alcohol abuse. It was implemented to protect the privacy of those seeking drug/abuse or addictions treatment to increase the chance that someone struggling with substances would seek help. Generally, if you are applying for or receiving services for drug or alcohol abuse, I may not acknowledge to a person outside the program that you attend the program or disclose any information identifying you as a substance abuse client except under certain circumstances as permitted by 42 CFR Part 2. Permitted circumstances are listed within this notice.
All Protected Health Information
The Health Insurance Portability and Accountability Act ("HIPAA") Privacy Regulations (45 CFR Parts 160 and 164), also protect your health information whether or not you are applying for or receiving services for drug or alcohol abuse. I have indicated within this notice when regulations and restrictions on PHI apply to both substance abuse clients and non-substance abuse clients or when they apply to substance abuse clients alone.
You will find in this notice under the heading All Protected Health Information circumstances listed in which PHI will be disclosed for both non-substance abuse clients and substance abuse clients. In such cases where it is identified, Without Your Consent: All Protected Health Information, no information will be disclosed identifying you as a substance abuse client.
Under the heading, Without Your Consent: Substance Abuse Clients Only, you will find situations listed where I may disclose your PHI without consent, and this may include PHI that identifies you as a substance abuse client.
Under the Heading, Without Your Consent Non-Substance Abuse Clients, you will find how I may disclose or use your PHI for clients seeking help for behavioral issues unrelated to personal substance abuse issues.
How I May Use and Disclose Your PHI
Uses and Disclosures WITH Your Consent/Authorization: All Protected Health Information
I may use or disclose your protected health information including substance abuse information when you consent that I can do so in writing.
For example, if you participate in marital or couples therapy, I will not disclose confidential information about your treatment unless you sign a release allowing me to discuss confidential information that includes your substance abuse treatment information.
Uses and Disclosures WITHOUT Your Consent or Authorization: All Protected Health Information
Even when you have not given your written consent or authorization, I may use and disclose information under the circumstances listed below. This list applies to All protected health information, including those seeking services for substance abuse services. However, the information disclosed would not identify you as a substance abuse client.
Healthcare Operations: I may use and disclose your Protected Health Information
to manage, operate, and support the business activities of my practice. These activities include, but are not limited to, quality assessment, employee review, licensing, fundraising, and conducting or arranging for other business activities.
Business Associates: I may have contracts with employee assistance programs, billing program vendors, and hardware and software vendors/maintenance individuals and companies and entities which are considered “Business Associates.” These Business Associates promise in writing to maintain the confidentiality of any PHI they are disclosed or come into contact with except as otherwise required by law. For instance, I may share your PHI with a business associate for the purpose of processing payment but will provide them only the information they will need to process your bill.
Other Ways I might Disclose Your PHI without your consent as Required or Permitted by Law
I am required by law to disclose your PHI in certain circumstances not already mentioned in this notice as outlined below.
1. To a public health authority for public health activities including the following: to prevent or control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
2. To someone assisting in disaster relief so that your family can be notified about your status and location.
3. To your court-appointed guardian or an agent appointed by you under a health care power of attorney.
4. To a health oversight agency for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies to monitor the health care system, government programs, and compliance with civil rights laws.
5. To a correctional institution (if you are an inmate) or a law enforcement official (if you are in that official’s custody) as necessary (i) for the institution to provide you with health care; (ii) to protect your or others’ health and safety; or (iii) for the safety and security of the correctional institution.
6. For workers’ compensation or similar work-related injury programs, to the extent required by law.
7. To military command authorities if you are a member of the armed forces.
8. To Coroners, medical examiners, and Funeral directors as necessary for them to carry out their duties.
9. To authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
10. To authorized federal officials so they can provide protection to the President or other authorized persons.
11. To emergency personnel if you are a danger to yourself or others: I may disclose your information if I learn that you pose a physical threat to yourself or someone else.
Use WITHOUT Your Consent Non-Substance Abuse Clients
Payment: Your protected health information may be used to obtain or provide payment for your healthcare services, including disclosures to other entities. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services I recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you, and undertaking utilization review activities. For example, we may need to give your insurance company information about therapy you received so your insurance will pay for the care.
Uses and Disclosures WITHOUT Your Consent/Authorization: Substance Abuse Clients Only
Audit and Evaluation Activities: I may disclose protected health information to those who perform audit or evaluation activities for certain health oversight agencies, e.g., state licensure or certification agencies.
Research: I may use or disclose protected health information without your consent or authorization for research purposes.
Medical Emergencies: I may disclose your protected health information to medical personnel to the extent necessary to meet a bona fide medical emergency (as defined by 42 CFR Part 2).
Judicial and Administrative Proceedings: I may disclose your protected health information in response to a court order that meets the requirements of federal regulations, 42 CFR, Part 2, concerning Confidentiality of Alcohol and Drug Abuse Patient Records.
Commission of a Crime on Premises or against Program Personnel: I may disclose your protected health information to the police or other law enforcement officials if you commit a crime on the premises or against me or threaten to commit such a crime.
Child Abuse: I may disclose your protected health information for the purpose of reporting child abuse and neglect as mandated by state law.
Quality Service Organizations: As with Business Associates, I may have contracted with certain outside entities to conduct business, and they may have access to your PHI that identifies you as a substance abuse client. However, I have a written Quality Service Organization Agreement (QSOA) with them in which they attest to protect your PHI, and this allows the disclosure without your consent as pursuant to federal regulations, 42 CFR, Part 2.
Uses WITH Your Consent Substance Abuse Clients:
Payment: With your consent, I will disclose your PHI for the purpose of obtaining payment. This would include providing identifying and treatment information to insurance companies to receive payment so you are not responsible for fees that would be covered by your private insurance company.
When sharing PHI with others outside of this office, I share only what is reasonably necessary unless we are sharing PHI to help treat you, in response to your written permission, or as the law requires.
Right to Receive Confidential Communications: Normally, I will communicate with you via the phone number and /or home address you provide. I have outlined how I might communicate with you in the Disclosures Statement and Informed Consent Document. You have the right to ask that I communicate your PHI to you in a certain way or a certain location. For example, you can request that I contact you only at your cell phone number or by mail at your home address. You will have the opportunity to tell me how you would like me to communicate with you at your first appointment or any appointment thereafter.
Right to Request Restrictions: At your request, I will not disclose health information to your health plan if the disclosure is for payment of a health care item or service for which you have paid out of pocket in full. You may request additional restrictions on my use and disclosure of protected health information for treatment, payment and health care operations. While I will consider requests for additional restrictions carefully, I am not required to agree to a requested restriction. If you wish to request additional restrictions whether you are current or former client please, contact me.
Right to Inspect and Copy Your Health Information: You may request access to your records maintained by me to inspect and request copies of the records. If you desire access to your records please contact me and inform me of this request. I will inform you at that time of the cost per copies. Please allow 72 hours for me to prepare your copies.
Right to Amend Your Records: You have the right to request that I amend protected health information maintained in your clinical file or billing records. If you desire to amend your records and you are currently receiving services, please contact me. Under certain circumstances, I have the right to deny your request to amend your records and will notify you of this denial as provided in the HIPAA regulations. If your requested amendment to your records is accepted, a copy of your amendment will become a permanent part of the medical record. When I “amend,” a record, I may append information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement of disagreement placed in your medical records.
Right to Receive an Accounting of Disclosures: Upon request, you may obtain a list of instances that I have disclosed your protected health information. If you request an accounting more than once during a twelve (12) month period, there will be a charge. You will be told the cost prior to the request being filled.
Right to Revoke Authorizations: You may revoke your authorization except to the extent that I have already acted upon the authorization. Drug and alcohol abuse clients can request revocation verbally. Non-substance abuse clients will need to provide their request in writing.
Right to Receive a Paper Copy of This Notice: I will provide you with a written copy of this notice and request your signature on this form verifying that you received it. A copy of the signed form will be kept in your file.
Right for Further Information and to Complain: For additional information about your rights, please see the Client’s Rights and Responsibilities Form. If you desire further information about your privacy and confidentiality rights, you may contact me at 1-812-200-8177. You may also contact me if you are concerned that I have violated your privacy rights. You may also file a written complaint with the Secretary of the United States Department of Health and Human Services by writing to:
U.S. Department of Health & Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Right to Know: You have the right to know that violations of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney’s Office or Substance Abuse and Mental Health Services Administration (SAMHSA) (See contact information below) in accordance with Federal regulations. See 42 U.S.C 290dd-3 and 42 U.S.C. 290ee for Federal laws and 42 CFR part 2 for Federal regulations.
United States Attorney’s Office /Southern Indiana District
10 W Market St, Suite 2100
Indianapolis, IN 46204
5600 Fishers Lane
Rockville, MD 20857
Right to Know: There is a restriction on use of your information. Information obtained by patient access to his or her patient record is subject to the restriction on use of this information to initiate or substantiate any criminal charges against the patient or to conduct any criminal investigation of the patient as provided for under 42 CFR part 2 [(§2.12(d)(1)].
I reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all your records that this practice has created or maintained in the past, and for any of your records that I may create or maintain in the future. I will always post a copy of my current Notice in my office in a visible location, and you have the right to request a copy of my most current Notice at any time. A copy will be posted on my website and any revision to it will be updated on the website accordingly. If you have any questions regarding this notice or our health information privacy policies, please contact me, Carla Janine Purvis, LCSW, LCAC at 812-200-8177
By signing this form, you acknowledge that you understand the above and have received a copy of this document.