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

MY COMMITMENT TO YOUR PRIVACY 

In order to provide you with quality care and to comply with certain legal requirements, I create a record of the care and services you receive. Your record contains personal information about you and your health. Information about you and your care that may identify you and that relates to your past, present, or future physical or mental health and related health care services is referred to as Protected Health Information (“PHI”). I am committed to maintaining the confidentiality of the clients I serve and the records I keep. I will only release healthcare information about you in accordance with federal and state laws, and the highest ethical standards of the counseling profession.

This notice describes my policies related to how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), and regulations promulgated under HIPAA including the HIPAA Privacy and Security Rule. 

Uses and disclosures of your health information for the purposes of providing services: Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes. 

• TREATMENT: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultants or treatment team members only with your authorization. 

• PAYMENT: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection. By providing your phone number and/or email address, you consent to be contacted regarding billing and payment for service by Self-Reliance Counseling, PLLC and it's agents, including collection agencies.

• HEALTHCARE OPERATIONS: I may need to use information about you to review or support our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or faxing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. 

• PSYCHOTHERAPY NOTES: I may keep “psychotherapy notes,” which are defined as notes that document or analyze the contents of a therapy session and are separated from the rest of your medical record (45 CFR § 164.501). Any use or disclosure of such notes requires your Authorization unless the use or disclosure is: 

  • For my use in defending myself in legal proceedings instituted by you.

  • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. 

  • Required by law and the use or disclosure is limited to the requirements of such law.

  • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

  • Required by a coroner who is performing duties authorized by law.

  • Required to help avert a serious threat to the health and safety of others.

SPECIAL PROTECTIONS FOR CERTAIN SUBSTANCE USE DISORDER RECORDS

Although Self Reliance Counseling, PLLC is not a federally assisted substance use disorder treatment program under 42 C.F.R. Part 2, I may receive records from other providers or programs that are subject to these federal confidentiality protections. When I receive such records, additional restrictions apply to their use and disclosure.

• Limits on Use and Disclosure: Substance use disorder (SUD) records that originate from a program subject to 42 C.F.R. Part 2 may not be used or disclosed for treatment, payment, or health care operations without the individual’s specific written consent, except as otherwise permitted or required by law. These protections are more stringent than those that apply to most protected health information (PHI) under HIPAA.

• Legal Proceedings: SUD treatment records received from Part 2–covered programs may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against the individual unless the disclosure is authorized by the individual’s written consent or permitted by a valid court order. Any court order authorizing such disclosure must comply with applicable federal law and be accompanied by a subpoena or other legal requirement compelling disclosure, following notice to the individual and an opportunity to be heard.

• Redisclosure: Once health information is shared with another person or organization, it may no longer be protected by federal privacy laws. However, SUD records that are subject to this federal law generally cannot be redisclosed unless the individual has given written permission or the law allows it.

MARKETING PURPOSES & SALE OF PHI

I do not use or disclose your PHI for marketing purposes. I will not sell your PHI.

OTHER USES AND DISCLOSURE OF YOUR INFORMATION NOT REQUIRING YOUR CONSENT:

Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

• For judicial and administrative proceedings, I may disclose your PHI pursuant to a subpoena, court order, administrative order or similar process, although our preference is to obtain authorization before doing so.

• I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena, court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises. 

• I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA. 

• I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. 

• I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm. 

• If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control

• I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm. 

• If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority. 

• I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. 

• I may also use or disclose your information to family members or friends that are directly involved in your treatment with your verbal permission. 

• Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices. 

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

• The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

• The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out of-pocket in full.

• The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

• The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

• The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

• The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request. 

• The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.  

For more information, please see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html