Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my 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 by posting a copy on my website, sending a copy to you in the mail upon request, or providing one to at your next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purposes of providing, coordinating, or managing your health care treatment and related services. This may include consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.
For Payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes or legal action due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations: I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g. billing, transcribing or typing services) provided I have a written contract with a business or an individual that requires them to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
As Required by Law: Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
Without Authorization: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
* Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department).
* Required by Court Order.
* For Safety Reasons, such as to prevent suicide, homicide, assault or any other serious and imminent threat to anyone’s health or safety. If, in my professional judgment, you are likely to harm yourself, I may notify a family member or a friend of yours to assist in maintaining your safety. If I have reason to believe that you have intent to harm someone else or pose a health threat to the community, I may disclose information to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
* Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this information as soon as reasonably practicable after the resolution of the emergency.
* For Military/National Security Reasons. If you are or were a member of the armed forces, or part of the national security or intelligence communities, military command or other government authorities may require the release of health information about you.
* Family Involvement in Care. I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
* In the Event of Your Death. When friends or family have been involved in providing or paying for your treatment, I may release your health information to them as it relates to billing or other practical matters related to death. A release of information regarding deceased clients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin.
* Health Oversight. If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
* Law Enforcement. I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document. The purpose for this disclosure would be the identification of a suspect, material witness or missing person, in connection with the victim of a crime, a deceased person, the reporting of a crime in an emergency, or in a crime on the premises.
*Public Health. If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information or to a government agency with whom they are collaborating for the purpose of preventing or controlling disease, injury, or disability.
*Research. PHI may only be disclosed after a special approval process or with your authorization.
REQUIRED STATEMENT REGARDING HOW SUBSTANCE USE INFORMATION MAY BE DISCLOSED
Use and Disclosure of Substance Use Disorder Records Subject to 42 CFR Part 2: If applicable, your substance use disorder (“SUD”) records are protected by federal law under 42 C.F.R. Part 2 (“Part 2”). This law provides extra confidentiality protections and requires a separate patient consent for the use and disclosure of SUD counseling notes. Each disclosure made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent. It must also be accompanied by a written notice containing the language in 42 CFR Part 2.32(a). Disclosure of these records requires your explicit written consent, except in limited circumstances such as: (a) Medical Emergencies: to the extent necessary to treat you, (b) Reporting Crimes on Program Premises, (c) Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect to appropriate state or local authorities, and (d) Fundraising: We will provide you with an opportunity to decline to receive any fundraising communications prior to making such communications. You may revoke this consent at any time.
Prohibitions on Use and Disclosure of Part 2 Records: SUD records received from programs subject to Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested SUD record is used or disclosed. If SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI.”
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request to me in writing at [email protected] or 3000 NE Stucki Avenue, Suite 230H, Hillsboro, Oregon 97124. Please make sure to verify that your message has been received.
Right to Revoke Your Consent: You have the right to revoke your consent at any time by giving me written notice. Your revocation will be effective when I receive it, but it will not apply to any uses or disclosures that occurred prior to that time.
Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. I reserve the right to charge a reasonable, cost-based fee for copies.
Right to Amend: If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment.
Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the 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 Notification of Any Accidental Breaches of Confidentiality: If there is an accidental breach of PHI—for example, if my computer is stolen or an email is sent to the wrong person—you have the right to be notified after a risk analysis is conducted. This analysis will take into account: the nature and extent of the PHI involved including the sensitivity of the information from a financial or clinical perspective and the likelihood the information can be re-identified; the person who obtained the unauthorized access and whether that person has an independent obligation to protect the confidentiality of the information; whether the PHI was actually acquired or accessed, determined after conducting a forensic analysis; and the extent to which the risk has been mitigated, such as by obtaining a signed confidentiality agreement from the recipient.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. 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 medical matters in a certain way or at a certain location.
Right to a Paper Copy of This Notice.
COMPLAINTS
If you believe I have violated your privacy rights, you have the right to file a complaint in writing with the Secretary of Health and Human Services at 200 Independence Ave., SW, Washington, DC 20201 or by calling (202)-619-0257.
I will not retaliate against you for filing a complaint.
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 checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my 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 by posting a copy on my website, sending a copy to you in the mail upon request, or providing one to at your next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purposes of providing, coordinating, or managing your health care treatment and related services. This may include consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.
For Payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes or legal action due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations: I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g. billing, transcribing or typing services) provided I have a written contract with a business or an individual that requires them to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
As Required by Law: Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
Without Authorization: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
* Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department).
* Required by Court Order.
* For Safety Reasons, such as to prevent suicide, homicide, assault or any other serious and imminent threat to anyone’s health or safety. If, in my professional judgment, you are likely to harm yourself, I may notify a family member or a friend of yours to assist in maintaining your safety. If I have reason to believe that you have intent to harm someone else or pose a health threat to the community, I may disclose information to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
* Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this information as soon as reasonably practicable after the resolution of the emergency.
* For Military/National Security Reasons. If you are or were a member of the armed forces, or part of the national security or intelligence communities, military command or other government authorities may require the release of health information about you.
* Family Involvement in Care. I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
* In the Event of Your Death. When friends or family have been involved in providing or paying for your treatment, I may release your health information to them as it relates to billing or other practical matters related to death. A release of information regarding deceased clients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin.
* Health Oversight. If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
* Law Enforcement. I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document. The purpose for this disclosure would be the identification of a suspect, material witness or missing person, in connection with the victim of a crime, a deceased person, the reporting of a crime in an emergency, or in a crime on the premises.
*Public Health. If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information or to a government agency with whom they are collaborating for the purpose of preventing or controlling disease, injury, or disability.
*Research. PHI may only be disclosed after a special approval process or with your authorization.
REQUIRED STATEMENT REGARDING HOW SUBSTANCE USE INFORMATION MAY BE DISCLOSED
Use and Disclosure of Substance Use Disorder Records Subject to 42 CFR Part 2: If applicable, your substance use disorder (“SUD”) records are protected by federal law under 42 C.F.R. Part 2 (“Part 2”). This law provides extra confidentiality protections and requires a separate patient consent for the use and disclosure of SUD counseling notes. Each disclosure made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent. It must also be accompanied by a written notice containing the language in 42 CFR Part 2.32(a). Disclosure of these records requires your explicit written consent, except in limited circumstances such as: (a) Medical Emergencies: to the extent necessary to treat you, (b) Reporting Crimes on Program Premises, (c) Child Abuse Reporting: In connection with incidents of suspected child abuse or neglect to appropriate state or local authorities, and (d) Fundraising: We will provide you with an opportunity to decline to receive any fundraising communications prior to making such communications. You may revoke this consent at any time.
Prohibitions on Use and Disclosure of Part 2 Records: SUD records received from programs subject to Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested SUD record is used or disclosed. If SUD records are disclosed to us or our business associates pursuant to your written consent for treatment, payment, and healthcare operations, we or our business associates may further use and disclose such health information without your written consent to the extent that the HIPAA regulations permit such uses and disclosures, consistent with the other provisions in this Notice regarding PHI.”
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request to me in writing at [email protected] or 3000 NE Stucki Avenue, Suite 230H, Hillsboro, Oregon 97124. Please make sure to verify that your message has been received.
Right to Revoke Your Consent: You have the right to revoke your consent at any time by giving me written notice. Your revocation will be effective when I receive it, but it will not apply to any uses or disclosures that occurred prior to that time.
Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. I reserve the right to charge a reasonable, cost-based fee for copies.
Right to Amend: If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment.
Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the 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 Notification of Any Accidental Breaches of Confidentiality: If there is an accidental breach of PHI—for example, if my computer is stolen or an email is sent to the wrong person—you have the right to be notified after a risk analysis is conducted. This analysis will take into account: the nature and extent of the PHI involved including the sensitivity of the information from a financial or clinical perspective and the likelihood the information can be re-identified; the person who obtained the unauthorized access and whether that person has an independent obligation to protect the confidentiality of the information; whether the PHI was actually acquired or accessed, determined after conducting a forensic analysis; and the extent to which the risk has been mitigated, such as by obtaining a signed confidentiality agreement from the recipient.
Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. 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 medical matters in a certain way or at a certain location.
Right to a Paper Copy of This Notice.
COMPLAINTS
If you believe I have violated your privacy rights, you have the right to file a complaint in writing with the Secretary of Health and Human Services at 200 Independence Ave., SW, Washington, DC 20201 or by calling (202)-619-0257.
I will not retaliate against you for filing a complaint.
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 checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
