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THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.We are required by law to maintain the privacy of your health information and provide you with a description of our privacy practices. This notice will also describe your rights and certain obligations we have regarding the use and disclosure of your health information.

PLEASE REVIEW THIS NOTICE CAREFULLY

Your health information is personal. We are committed to protecting your health information. We create a record of the care and services you receive at this office. We need this record to provide you with quality care and comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office whether made by your therapist or one of the office's employees.

I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations  

The following describes the different ways that your protected health information (PHI) may be used or disclosed by this office. "PHI" refers to information in your health record that could identify you. For clarification, we have included some examples. Not every possible use of disclosure is specifically mentioned. However, all of the ways we are committed to use and disclose your "PHI" will fit within one of these general categories:

·        For Treatment. "Treatment" is when we provide, coordinate, or manage your health care and other services related to your health care.  An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.

·        For Payment. "Payment" is when we obtain reimbursement for your healthcare.  Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. We may also tell your health plan insurer about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover or continue to cover your treatment.

·        For Healthcare Operations. "Healthcare Operations" are activities that related to the performance and operation of our practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. We may use and disclose health information to provide you with appointment information. This may be done with voice mail, messages, post cards, and other mailings.

·        Use. "Use" applies only to activities within our office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

·        Disclosure. “Disclosure” applies to activities outside of our office such as releasing, transferring, or providing access to information about you to other parties.

II.  Uses and Disclosures Requiring Authorization 

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.  An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.  In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information.  We will also need to obtain an authorization before releasing your Psychotherapy Notes.  “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record.  These notes are given a greater degree of protection than PHI.

 You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.


ROI.pdf

III.  Uses and Disclosures with Neither Consent nor Authorization
 
We may use or disclose PHI without your consent or authorization in the following circumstances: 

 ·        Child Abuse. If we have reasonable cause to suspect child abuse or neglect, we must report this suspicion to the appropriate authorities as required by law.

·        Adult and Domestic Abuse. If we have reasonable cause to suspect you have been criminally abused, we must report this suspicion to the appropriate authorities as required by law.

·        Health Oversight Activities. If we receive a subpoena or other lawful request from the Oregon State Board of Nursing, we must disclose the relevant PHI pursuant to that subpoena or lawful request.

·        Judicial and Administrative Proceedings. If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and we will not release information without your written authorization or a court order.  The privilege does not apply when you are being evaluated or a third party or where the evaluation is court ordered.  You will be informed in advance if this is the case.

·        Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may use your PHI to defend the office or to respond to a court order.

·        Law Enforcement. We may release PHI about you if required by law when asked to do so by a law enforcement official.

·        Serious Threat to Health or Safety. If you communicate to us a threat of physical violence against a reasonably identifiable third person and you have the apparent intent and ability to carry out that threat in the foreseeable future, we may disclose relevant PHI and take the reasonable steps permitted by law to prevent the threatened harm from occurring.  If we believe that there is an imminent risk that you will inflict serious physical harm on yourself, we may disclose information in order to protect you.

·        Worker’s Compensation. We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

 IV.  Patient’s Rights and Clinician's Duties

 You have the following rights regarding the PHI that this office maintains about you.

 ·       Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information.  However, we are not required to agree to a restriction you request.

·        Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.  (For example, you may not want a family member to know that you are being seen at our office.  On your request, we will send your bills to another address.)  To request confidential communications, you must complete our request form in writing and submit it to the Privacy Officer. We will accommodate all reasonable requests.

·        Right to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  To inspect and/or obtain a copy of your PHI, you must complete our request form and submit it to the Privacy Officer.  If you request copies, we will charge you $0.10 per page. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, we will discuss with you the details of the request and denial process.

·        Right to Amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  To request an amendment, you must complete our request form and submit it in writing to the privacy officer. In addition, you must provide a reason that supports your request. We may deny your request.  On your request, we will discuss with you the details of the amendment process.

·        Right to an Accounting. You generally have the right to receive an accounting of disclosures of PHI.  On your request, we will discuss with you the details of the accounting process. To request this accounting on disclosures, you must complete a request form and submit it in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six (6) years and may not include dates before April 14, 2003.

·        Right to a Paper Copy. You have the right to obtain a paper copy of the Notice from us upon request.

 
Provider Duties:

·        We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

·        We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. 

 V.  Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact the Privacy Officer at Solarity Mental Health, PC listed below.

 If you believe that your privacy rights have been violated and wish to file a complaint with us/our office, you may send your written complaint to Solarity Mental Health, PC. All complaints must be submitted in writing to:

Jolyn Zeller, PMHNP-BC

3787 River Rd N Suite A
Keizer OR, 97303

503-763-1778

 You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  The person listed above can provide you with the appropriate address upon request.

 You have specific rights under the Privacy Rule.  We will not retaliate against you or penalize you in any way for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

 This notice will go into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. If we revise our policies and procedures, we will post a copy of any revised Notice in this office.

 Other uses and disclosures of your PHI not covered by this Notice of Privacy Practices will be made only with your written authorization. If you provide us such an authorization in writing to use or disclose PHI about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. Be aware that we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of care that we provide to you.

You may request this information in writting at your appointment.