Privacy Practices at The Play Therapy Center

NOTICE OF PRIVACY PRACTICES

YOUR INFORMATION. YOUR RIGHTS. MY RESPONSIBILITIES

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you. You must put this request in writing and specify what you are requesting.

I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.

Ask me to correct your medical record

You can ask me to correct health information about you that you think is incorrect or incomplete. You must put this request in writing and specify what information is incorrect or incomplete.

I may say “no” to your request, but I will tell you why in writing within 60 days.

Request confidential communications

You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

I will say “yes” to all reasonable requests.

Ask me to limit what I use or share

You can ask me not to use or share certain health information for treatment, payment, or our operations.

I am not required to agree to your request, and I may say “no” if it would affect your care.

If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer.

I will say “yes” unless a law requires me to share that information.

Get a list of those with whom I have shared information

You can ask for a list (accounting) of the times I have shared your information for six years prior to the date you ask, who I share it with, and why.

I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). I will provide one accounting a year for free but will charge reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.

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 health information.

I will make sure the person has this authority and can act for you before I take any action.

File a complaint if you feel your rights are violated

You can complain if you feel I have violated your rights by contacting me using the information on the back page.

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 visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

I will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk with me. Tell me what you want me to do, and I will follow your instructions.

In the cases, you have both the right and choice to tell me to:

Share information with your family, close friends, or others involved in your care

Share information in a disaster relief situation

If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interests. I may also share information when needed to lessen a serious and imminent threat to health or safety.

In these cases, I never share your information unless you give me written permission:

Marketing purposes

Sale of your information

Most sharing of psychotherapy notes

My Uses and Disclosures

How do I typically use or share your health information? I typically use or share your health information in the following ways.

Treat you

I can use your health information and share it with other professionals who are treating you. (Example: a doctor treating you for an injury asks another doctor about your overall health condition).

Run my practice

I can use and share your health information to run my practice, improve your care, and contact you when necessary. (Example: I use health information about you to manage your treatment and services.

Bill for your services

I can use and share your health information to bill and get payment from health plans or other entities. (Example: I give information about you to your health insurance plan so it will pay for your services).

My Uses and Disclosures

How else can I use or share your health information?

I am allowed or required to share your information in other ways-usually in ways that contribute to the public good, such as public health and research. I must meet many conditions in the law before I can share your information for these purposes. For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

I can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing serious threat to anyone’s health or safety

Do research

I can use or share your information for health research.

Comply with the law

I 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 I am complying with federal privacy law.

Respond to organ and tissue donation requests

I can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

I can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

I can use or share 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
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

My Responsibilities

I am required by law to maintain the privacy and security of your protected health information.

I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

I must follow the duties and privacy practices described in this notice and give you a copy of it.

I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me 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

I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in our office, and on our website.

This Notice of Privacy Practices applies to the following:

James Carroll, LCPC

1115 Frontage Rd.

Suite B

O'Fallon, IL 62269

Privacy Official: James Carroll, LCPC

jamie@counselor.hush.com

314-651-6679