Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. State and federal law protects
the confidentiality of this information. "Protected Health Information" (PHI) is information about you,
including demographic information, that may identify you and that relates to your past, present or future
physical or mental health or condition and related health care services.
Your Rights Regarding Your PHI
You have the following rights regarding PHI I maintain about you:
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain
limited circumstances, to inspect and copy PHI that may be used to make decisions about your care. I
may charge a reasonable, cost-based fee for copies.
- Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may
ask me to amend the information although I am not required to agree to the amendment.
- Right to an Accounting of Disclosures. You have the right to request a copy of the required
accounting of disclosures that I make of your PHI.
- Right to Request Restrictions. You have the right to request a restriction or limitation on
the use or of your PHI for treatment, payment, or health care operations. I am not required to agree
to your request.
- Right to Request Confidential Communication. You have the right to request that I communicate
with you about medical matters in a certain way or at a certain location. I will accommodate reasonable
requests and will not ask why you are making the request.
- Right to a Copy of this Notice. You have the right to a paper copy of this notice.
- Right of Complaint. You have the right to file a complaint in writing with me or with the Secretary
of Health and Human Services if you believe I have violated your privacy rights. I will not retaliate
against you for filing a complaint.
My Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
- Treatment. Your PHI may be used and disclosed by me for the purpose of providing, coordinating,
or managing your health care treatment and any related services. This may include coordination or management
of your health care with a third party, consultation with other health care providers or referral to
another provider for health care services.
- Payment. I will not use your PHI to obtain payment for your health care services without your
written authorization. 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.
- Healthcare Operations. I may use or disclose, as needed, your PHI in order to support the business
activities of my professional practice. Such disclosures could be to others to provide planning, quality
assurance, peer review, administrative, legal, or financial services to assist in the delivery of health
care, provided I have a written contract requiring the recipient(s) to safeguard the privacy of your
Other Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Obiect
- Required by Law. I may use or disclose your PHI to the extent that the use or disclosure is
required by law, made in compliance with the law, and limited to the relevant requirements of the law.
Examples are public health reports and law enforcement reports. I also must make disclosures to the
Secretary of the Department of Health and Human Services for the purpose of investigating or determining
my compliance with the requirements of the Privacy Rule.
- Health Oversight. I may disclose PHI to a health oversight agency for activities authorized
by law such as professional licensure. Oversight agencies also include government agencies and organizations
that provide financial assistance to me (such as third-party payers).
- Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by
law to receive reports of abuse or neglect. However, the information I disclose is limited to only that
information which is necessary to make the initial mandated report.
- Death. I may disclose PHI regarding deceased patients for the purpose of determining the cause
of death, in connection with laws requiring the collection of death or other vital statistics, or permitting
inquiry into the cause of death.
- Threat to Health or Safety. I may disclose PHI when necessary to prevent a serious threat to
your health and safety or the health and safety to the public or another person.
- Criminal Activity on My Business Premises/Against Me and My Staff. I may disclose your PHI
to law enforcement officials if you have committed a crime on my premises or against me or my colleagues.
- Compulsory Process. I will disclose your PHI if a court of competent jurisdiction issues an
appropriate order. I will disclose your PHI if you and I have each been notified in writing at least
fourteen in advance of a subpoena or other legal demand, and no protective order has been obtained,
and I have satisfactory assurances that you have received notice of an opportunity to have limited or
quashed the discovery demand.
Uses and Disclosures of PHI With Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke
this authorization in writing at any time, unless I have taken an action in reliance on the authorization
of the use or disclosure you permitted, such as providing you with health care services for which I
must submit subsequent claim(s) for payment.
This Notice of Privacy Practices describes how I may use and disclose your protected health information
("PHI") in accordance with all applicable law. It also describes your rights regarding how you may gain
access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you
with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by
the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice
of Privacy Practices at any time. Any new Notice of Privacy Prdctices will be effective for all PHI
that I maintain at that time. I will make available a revised Notice of Privacy Practices by posting
a copy on my Web site at http://home.earthlink.net/~lynn.fitzhugh/privacy.html.
I am my own Privacy Officer. So, if you have any questions about this Notice of Privacy Practices, please
contact me. My contact information Is: 1424 N.E. 155th St. #204, Shoreline, WA 98115, 206-713-497, firstname.lastname@example.org.
If you believe I have violated your privacy rights, you may file a complaint in writing to me, as my
own Privacy Officer, specified on the first page of this Notice. I will not retaliate against you for
filing a complaint. You may also file a complaint with the U.S. Secretary of Health and Human Services
at 200 Independence Avenue, S.W., Washington, D.C. 20201 - (202) 619-0257.
The effective date of this notice is April 14, 2003.
[Click here for more information about Lynn Fitz-Hugh's counseling services]