I understand that your health/mental heath information is personal and I am committed to protecting this information. I am required by applicable federal and state law to maintain the privacy of your health information. The Health Insurance Portability and Accountability Act of 1996 (HIPPA), also requires that I give you this Notice about my legal duties, my privacy practices, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice while it is in effect.

Individually identifiable information about your past, present, or future health/mental health or condition, the provision of health/mental health care to you, or payment for your health/mental health care is considered “Protected Health Information (PHI).” Whenever possible, the PHI contained in your record remains private. In some circumstances, it is necessary for me to share some of the PHI contained in your record. In all but certain specified circumstances, I will share only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.

I reserve the right to change this notice and to make changes in my privacy practices. Any changes will be effective for all PHI that I maintain, including health/mental health information created or received before I made the changes. You may request a current copy of this notice from me.

For Treatment: I may use/disclose your PHI to provide you with mental health treatment or services. For example, I can disclose your PHI to physicians, psychiatrists, and other licensed health care providers who provide you with health care services or are involved in your care. If a psychiatrist is treating you, I can disclose your PHI to your psychiatrist in order to coordinate your care.

For Payment: I may use/disclose your PHI in order to bill and collect payment .

Appointment Reminders or Changes in Appointment: I may use/disclose your PHI to contact you as a reminder that you have an appointment. I may contact you to notify you of a change in your appointment. For example, if I am ill, I may have someone in my office contact you to notify you that the appointment is cancelled.

When Disclosure is required by state, federal or local law; judicial or administrative proceedings; or law enforcement: I must use/disclose your PHI when a law requires that I report information about suspected child, elder or dependent adult abuse or neglect; or in response to a court order. I must also disclose information to authorities that monitor compliance with these privacy requirements.

To Avoid Harm: I may use or disclose limited PHI about you when necessary to prevent or lessen a serious threat to your health or safety, or the health and safety of the public or another person. If I reasonably believe you pose a serious threat of harm to yourself, I may contact family members or others who can help protect you. If you communicate a serious threat of bodily harm to another, I will be required to notify law enforcement and the potential victim.

Law Enforcement Officials: I may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or grand jury or administrative subpoena.

As Required by Law: I may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.

Disclosures of PHI For Which a Signed Authorization is Required: For uses and disclosures of PHI beyond the areas noted above, I must obtain your written authorization. Authorizations can be revoked at any time in writing to stop further uses/disclosures (except to the extent that I have already acted upon your authorization).

Right to Inspect and Copy: You have the right to inspect and copy your health/mental health information upon your written request. However, some mental health information may not be accessed for treatment reasons and for other reasons pertaining to federal law. I will respond to your written request to inspect records. A charge for copying, mailing and related expenses will apply.

Right to Restrict Restrictions: You have the right to ask that I limit how I use or disclose your PHI. I will consider your request, but I am not legally required to agree to the request. If I do agree to your request, I will put it into writing and comply with it except in emergency situations. I cannot agree to limit uses and/ or disclosures that are required by law.

Right to Amend: If you believe that there is a mistake or missing information in my record of your health/ mental health information, you may request, in writing, that I correct or add to the record. I will respond to our request within 60 days of receiving it. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request to amend information that: was not created by me, not part of my records, not part of the information that you would be permitted to inspect and copy or is accurate and complete.

Right to Request Confidential Communications: You have the right to request that I communicate with you about health/mental health matters in a certain way or at a certain location. For example, you may ask that I only contact you at work or by mail. To request confidential communications, you must make your request in writing. Please specify how or where you wish to be contacted. I will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have a right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time.

If you think that your privacy right have been violated you may contact us directly, or you may file a complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. You will not be penalized for filing a complaint.

If there are any questions regarding this privacy policy you may contact us using the information below:

A Couples Place Inc.
Lisa@aCouplesPlace.com

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