PRIVACY NOTICE Rev. 02/14
Privacy Officer: Dr. Daniel S. Bingham (email: email@example.com; phone: (734) 369-3180)
At Cypress Counseling Center, P.C. (CCC), protected health information (PHI) is handled responsibly. Below are the procedures utilized to safeguard PHI, the circumstances under which your personal health information may be disclosed, and your rights as they relate to this information. The rules for confidentiality of mental health records are recorded in the privacy rules of the Health Insurance Portability and Accountability Act (HIPAA). It is in your best interests to review these provisions in order to fully understand CCC’s procedures and your rights.
We strive to protect your personal health information (PHI).
At Cypress Counseling Center, P.C. (CCC), every effort is made to keep your PHI private. If you have any questions or concerns about your privacy, please address them with your therapist.
You are entitled to copy or review your mental health records.
You have the right to ask to see or get a copy of your mental health record. CCC will provide a copy or a summary of your mental health information, usually within 30 days of your request. A reasonable, cost-based fee may be assessed. You can ask CCC to correct health information about you that you think is incorrect or incomplete. CCC may say “no” to your request, but you will be given a reason why in writing within 60 days.
You can request confidential communications.
You have the right to ask CCC to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
You can request limitations on information sharing.
You have the right to ask CCC not to use or share certain information for treatment, payment, or mental health care operations. CCC is not required to agree with your request and might say “no” if it would affect your care. If you pay for counseling services out-of-pocket in full, you can ask CCC not to share that information for the purpose of payment or or our operations with your insurance company. CCC will say “yes” unless a law requires the information to be shared.
You can request a list of those with whom CCC has shared information.
You have the right to ask for a list (accounting) of the times CCC has shared your mental health information for up to six years prior to the date you ask, who it has been shared with, and why. CCC will provide one accounting per year year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
You can obtain a copy of this privacy notice.
You have the right to ask for a paper copy of this notice at any time. You will be provided one promptly.
You can choose 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 and make choices about your mental health information. CCC will ensure the person has this authority and can act for you before taking any action.
You can file a complaint if you feel your rights are violated.
You can complain if you feel CCC has violated your rights by contacting the office via the contact information listed on page one. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visitingwww.hhs.gov/ocr/privacy/hipaa/complaints/. CCC will not retaliate against you for filing a complaint.
For certain information, you can tell CCC your choices about what to share.
If you have a clear preference for how your information is shared in the situations described below, let CCC know and your instructions will be followed. Please note: CCC does not use your PHI for marketing purposes and does not sell it.
In these cases, you have both the right and choice to tell CCC to: 1) share information with your family, close friends, or others involved in your care; 2) share information in a disaster relief situation.
If you are unable to tell CCC your preference, for example if unconscious, CCC may share your information if it is in your best interests. CCC may also share your information when needed to lessen a serious and imminent threat to health or safety.
Other Uses and Disclosures
CCC typically uses or shares your mental health information in the following ways:
1) Providing treatment: CCC can use your mental health information and share it with other professionals who are treating you.
Example: A doctor treating you asks another doctor about your overall mental health condition.
2) Running this organization:CCC can use and share your mental health information to run this practice, improve your care, and contact you when necessary. Example: CCC uses information about you to manage your treatment and services.
3) Billing your services:CCC can use and share your information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
CCC is also allowed or required to share your information in the following ways:
CCC may use your information in ways that contribute to the public good, such as public health and research. Many conditions in the law have to be met before your information can be shared for these purposes.
For more information, see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
- Help with public health and safety issues: CCC can share health information about your for certain situations such as preventing disease, help with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
- Comply with the law: CCC will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that CCC is complying with federal privacy law.
- Address workers’ compensation, law enforcement, and other governmental requests: CCC can use or share mental health information about you for workers’ compensation claims, for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, and for special government functions such as military, national security, and presidential protective services.
- Respond to lawsuits and legal actions: CCC can share mental health information about you in response to a court or administrative order, or in response to a subpoena.
The following individuals can access a mental health record without written authorization.
1) An adult recipient of services; 2) the parent or guardian of a child who is under 12 years of age; 3) a recipient who is 12 years of age or older; 4) the parent or guardian of a recipient who is at least 12, but under 18, if the recipient does not object or if the therapist does not find compelling reason for denying access; 5) a legal guardian of a recipient who is 18 or older. CCC provides assistance in understanding the mental health record.
CCC is required by law to maintain the privacy and security of your PHI. You will be informed promptly if a breach occurs that may have compromised the privacy or security of your information. CCC is obligated to follow the duties and privacy practices described in this notice and provide you a copy of it. CCC will not use or share your information other than as described here unless you provide consent in writing. Once you have provided consent, you may change your mind at any time. Let CCC know in writing if you change your mind.
For more information see: www. hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice