HIPAA Privacy Practice Notice

Wayfinder Integrative Solutions, LLC

Dr. Jennifer Girard, DBH, LPC, LAC

P.O. Box 1058 Eagle, CO 81631

970.239.1040

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO IT. PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from me. We need this record to provide you with quality care and to comply with certain legal and ethical requirements. This notice applies to all of the records of your care generated or used by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.
  • Give you this notice of my legal duties and privacy practices with respect to your PHI.
  • Promptly notify you if any breach occurs in the privacy or confidentiality of your PHI that we maintain.
  • Follow the terms of the current version of this notice.

We may change the terms of this Notice from time-to-time, and such changes will apply to all information we have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. Below are some illustrative examples of uses. Those examples are not meant to be exhaustive or to describe every way we may use your PHI. However, all of the ways we are permitted to use and disclose your PHI will fall within one of the following categories. We may collect, use, or disclose your PHI without your consent for the following purposes:

TREATMENT. We may use or disclose health information to:

·       Provide, manage, or coordinate care.

·       Consultants.

·       Referral sources.

PAYMENT. We may use and disclose health information to:

·       Verify insurance and coverage.

·       Process claims and collect fees.

HEALTHCARE OPERATIONS. We may use and disclose health information for:

·       Review of treatment procedures.

·       Review of business activities.

·       Certification.

·       Staff training.

·       Compliance or licensing activities.

OTHER USES. We may use and disclose health information for:

·       Mandated reporting, including for child or elder abuse or neglect.

·       Reporting suspected abuse to oneself or others, neglect, or domestic violence.

·       Emergencies.

·       Criminal damage.

·       Appointment scheduling.

·       Treatment alternatives.

·       To a family member or coroner after the client’s death or disability.

·       Legal defense to an action or claim instituted by you or your representative.

·       As required by law or valid court order.

Specific Examples: For example, we may use and disclose your PHI without your consent for treatment, payment, or health care operations. Federal privacy rules and regulations allow health care providers who have a direct treatment relationship with a patient/client to use or disclose the patient/client’s PHI without the patient’s written authorization to carry out the health care provider’s own treatment, payment, or health care operations. We may also disclose your PHI without your authorization while working with any consultant or referred health care provider, and generally for providing, managing and coordinating care. For example, if we consult with another licensed health care provider about your condition, we would be permitted to use and disclose your PHI, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health or medical condition. Access to a patient/client’s full record facilitates better care.

We may also use and disclose your PHI in lawsuits and disputes. If you are involved in a lawsuit, we may disclose your or your child’s health information, where applicable, in response to a lawful court or administrative order. We may also disclose this PHI in response to a discovery request, or other lawful process by someone else involved in the dispute, if applicable, but only where the requesting party has informed you of the discovery request and provided you an opportunity to obtain an order protecting the requested information.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

  1. 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.
  2. 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.
  3. 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.
  4. The Right to See and Get Copies of Your PHI. Other than my charting and 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 30 calendar days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
  5. 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 60 calendar 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.
  6. The Right to Correct or Update 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 60 calendar days of receiving your request.
  7. 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.

8.     The Right to File a Complaint, including with the Secretary of Health and Human Services at 200 Independence Avenue, S.W.  Washington, D.C. 20201 if you believe your privacy rights have been violated.

9.     Get a copy of this privacy notice.

10.  Choose someone to act for you in regard to this privacy notice and your PHI.

Please ask us for more information regarding how you can manage any of these methods of use of your information, or about any other issue in this notice.

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 this Wayfinder Integrative Solutions, LLC’s HIPAA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.