Notice Of Privacy Practices: Doña Ana

FOR DOÑA ANA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant.

  • Notice Of Privacy Practices: Doña Ana
    ID #
  • MM slash DD slash YYYY

  • Notice Of Privacy Practices
  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your “protected health information” (PHI) tocarryout our treatment, payment or health care operations and for other purposes that are required by law. It also describes your rights to access and control your PHI. PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

    We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at anytime. The new notice will be effective for all PHI that we maintain at the time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

    USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION: Your PHI may be used and disclosed by your therapist and others outside of this office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of the therapists practice. Following are examples of the types of uses and disclosures of your PHI that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by this office.

    TREATMENT: We will use and disclose your PHI to provide, coordinate or manage your care and any related services.

    PAYMENT: Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

    HEALTHCARE OPERATIONS: We may use or disclose, as needed, your PHI in order to support the business activities of your therapists practice. The following are examples of uses/disclosures for Health Care Operations that your therapists’ office may perform:

    A. Uses and disclosures of PHI based on your written authorization: Other uses of your PHI will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that your therapist or therapist’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

    B. Other permitted and required uses and disclosures that may be made without your authorization or opportunity to object: We may use or disclose your PHI in the following situations without your authorization.

    REQUIRED BY LAW: We may use or disclose your PHI to the extent that law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such disclosures.

    HEALTH OVERSIGHT: We 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 regulatory programs and civil rights laws.

    ABUSE OR NEGLECT: We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse, neglect or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made with the requirements of applicable federal and state laws.

    LEGAL PROCEEDINGS: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

    LAW ENFORCEMENT: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include:

    1. legal processes and otherwise required by law,
    2. limited information requests for identification and location purposes,
    3. pertaining to victims of a crime,
    4. suspicion that death has occurred as a result of criminal conduct,
    5. in the event that a crime occurs on the premises of the practice, and
    6. medical emergency (not on the practices premises) and it is likely that a crime occurred.

    CRIMINAL ACTIVITY: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

    MILITARY ACTIVITY AND NATIONAL SECURITY: When the appropriate conditions apply, we may use or disclose PHI of individuals who are armed forces personnel:

    1. for activities deemed necessary by appropriate military command authorities;
    2. for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or
    3. to foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

    WORKERS’ COMPENSATION: Your PHI may be disclosed as authorized to comply with workers’ compensation laws and other similar legally established programs. Required Uses and Disclosures: Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq.

    YOUR RIGHTS: Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

    YOU HAVE THE RIGHT TO INSPECT AND COPY YOUR PROTECTED HEALTH INFORMATION. You may inspect and obtain a copy (at your expense) of PHI about your in a designated record set for as long as we maintain the PHI. A designated record set contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.

    Under Federal Law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in a reasonable anticipation of, or use in , a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be review able. In some circumstances, you may have the right to have this decision reviewed.

    YOU HAVE THE RIGHT TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

    Your Therapist is not required to agree to a restriction that you may request. If the Therapist believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your Therapist does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your therapist. You may request a restriction by submitting a written request to your Therapist.

    YOU HAVE THE RIGHT TO REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATIONS FROM US BY ALTERNATIVE MEANS OR AT AN ALTERNATIVE ADDRESS. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis of your request. Please make this request in writing to your Therapist.

    YOU HAVE THE RIGHT TO REQUEST AMENDMENTS TO YOUR PHI. You may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. Please contact your Therapist to determine if you have questions about amending your medical record.

    You have the right to receive an accounting of certain disclosures we have made of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations and described in this Notice of Privacy Practices. It excludes disclosures we may have made to you for a facility directory, to family members or friends involved in your care, or for notification purposes. Disclosures made pursuant to a signed authorization by you are also excluded from the accounting. You have the right to receive specific information regarding these disclosures that occurred after October 1, 2004. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. The first request will be done at no charge, but any subsequent requests will be at your expense.

    COMPLAINTS: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying your Therapist, in writing, of your complaint. We will not retaliate against you for filing a complaint.


  • MM slash DD slash YYYY