Notice of Privacy Practices Document

Notice of Privacy Practices                                                     

Impact Counseling & Guidance Center

Effective April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Impact Counseling and Guidance Center (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

 

UNDERSTANDING YOUR PRIVATE HEALTH INFORMATION: Each time you visit a hospital, physician, mental health professional or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, and treatment. In the case of a mental health professional, it contains psychotherapy notes and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

 • Basis for planning your care and treatment.

 • Means of communication among the many health professionals who contribute to your care.

 • Legal document describing the care you received.

 • Means by which you or a third-party payer can verify that services were provided.

 • A source of information for public health officials charged with improving the health of the nation.

 • A source of data for facility planning and marketing.

 • A tool with which we can assess and continually work to improve the care we render and the   outcomes we achieve.

 • A tool in educating health professionals.

 

Understanding what is in your record and how your health information is used helps you to:

 • Ensure its accuracy.

 • Better understand who, what, when, where, and why others may access your health information.

 • Make more informed decisions when authorizing disclosure to others.

 

YOUR RIGHTS: Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

 

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice will charge a fee of $.10 per page. If you chose to not pick up paper copies in person, you will be charged an additional cost to send the records certified mail. If you authorize someone else to sign for and receive paper

documents in person or by mail, we must have a signed release from you on file, concerning the person you have authorized, prior to release of documents. For the release of electronic copies to anyone other than the client, a signed release must be on file, concerning the person authorized to receive the electronic transmission, prior to the release of documents.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice will require you to make your request in writing and provide a reason for the request. The Practice will act on your request within sixty (60) days, but this deadline may be extended for another thirty (30) days upon written notice to you.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• The Practice does not file insurance; therefore, you are paying the Practice in full for services rendered. If you choose to file for reimbursement with your health care provider, we will give you a diagnostic code to submit. You can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called Accounting, of the times your health information has been shared within the past 6 years. Disclosures that are exempted from the accounting requirement include the following:

• Disclosures that are necessary to carry out treatment, payment and health care options.

• Disclosures that are made to you upon request.

• Disclosures made pursuant to your authorization.

• Disclosures made for national security or intelligence purposes.

• Permitted disclosures to correctional institutions or law enforcement officials.

• Disclosures that are a part of a limited data set used for research, public health or health care operations.

 

 We are required to act on your request for an Accounting within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which we will provide the accounting. You can receive one accounting every 12 months at no charge, but you will be charged a fee of $.10 for each copied page if you ask for one more frequently.
 

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

 

 Choosing someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
 

To file a complaint:
• Dr. Ed Laymance is the Director of Impact Counseling and Guidance Center and may be contacted regarding any complaints in writing or by phone at:

Impact Counseling and Guidance Center
2912 Little Road, Arlington, Texas 76016
817-457-6728
 

• In addition, you can file a complaint with Texas Behavioral Health Executive Counsel, 333 Guadalupe St., Ste. 3-900, Austin Texas, 78701. The phone number is 512-305-7700.

 • The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.
 

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object

The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:
 

To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.

 • Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.

 • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

• Serious threat to health or safety: To prevent a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request. This includes divorce and/or child custody cases and other legal proceedings in which your mental health or condition is in issue. NOTE: It is our policy to not be involved in legal issues regarding divorce or child custody disputes. However, in the event disclosure of your records or the Provider’s testimony/deposition are required by law, you will be responsible for all costs to Impact Counseling and Guidance Center for these services, and shall pay the costs involved, including but not limited to:

postage/currier fees/communication services, legal fees, travel expenses, cost of producing necessary records, and the Provider’s normal session rate per hour for the total number of hours it takes in preparation for and/or in giving testimony in court or depositions.

 • Legal Disputes: to defend ourselves in a legal action or other proceeding brought by you against us. In addition, to file a suit for collection of fees for our services.
• Law enforcement: For law to locate and identify you or disclose information about a victim of a crime or if we believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on our premises.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.

• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.

 

To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made with Your Authorization or Opportunity to Object

Unless you object, the Practice may disclose PHI: To your family, friends, or others if PHI directly relates to that person's involvement in your care or if it is in your best interest because you are unable to state your preference.
 

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes: Marketing, sale of PHI, and psychotherapy notes.

 

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

 

OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above.
• The Practice will inform you if PHI is compromised in a breach.

If you have any questions or concerns regarding your PHI, you may contact Tonya Trentham, our Privacy Officer, at (817) 457-6728. If you need to file a complaint regarding your privacy rights, you may contact the Department of Health and Human Services at 1-866-627-7748.

 

 

 

 

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