NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY

Your medical information is personal. Grody Family Counseling is committed to protecting your medical information. We are required by law to:

 Maintain the privacy of your health information;

 Give you this Notice of our legal duties and privacy practices;

 And follow the terms of this Notice.

Possible Uses and Disclosures of Your Medical Records

There are many ways in which your medical information can be used and disclosed. Some of the following categories list examples of how information can be disclosed. Not every use or disclosure will be listed. All the ways use is permitted fall into one of the following categories:

For Treatment: If you sign a release authorizing these actions, I may do the following:

 Use your medical information about you to provide you with treatment and services;

 Disclose your information to other doctors or healthcare professionals who are involved in your care.

 Disclose your medical information to people who are involved with your healthcare, such as family members.

 Disclose your medical information to another healthcare facility or healthcare professional that is or is going to be involved in your healthcare.

For Payment: If you sign a release authorizing these actions, I may do the following:

 Use and disclose your medical information to your insurance company to assist you with reimbursement from your insurance company for fees paid out-of-pocket to me. Please note that such information may include information that identifies you and/or your family members as well as any diagnosis and interventions. I may need to give your insurance company information from your session notes so that they will reimburse you for those services.

 I believe sending a client to collections for past due payments is an unethical release of information about my clients. As a result, I require payment at the time of services.

Appointment Reminders and Phone Contact:

 I may contact your for scheduling or reminding you of an appointment, returning your call, answering questions, or informing you about treatment alternatives and test results.

 I may contact you by mail or I may call you. If I contact you by mail, I will address the card or envelope to you.

 Test results or other health information will be sent in a sealed envelope.

 If I contact you by phone, I simply will identify myself and ask to speak with you. If you are not available, I will leave a message with the person who answered the phone asking you to call me. If you have voice mail, I will leave a message identifying myself and telephone number with a message for you to return my call, but I will not disclose any information.

 Please let me know if you do not want me to leave a message on your voice mail.

Family and Friends:

 I may release medical information about you to a friend or family member who is involved in your care if we have a signed consent form on file.

Business Associate:

 I am not using any services that require me to release your health information to business associates.

 If I bring in another clinician to assist with your case, I will only do so after receiving a written release of permission from you.

For Safety Purposes:

 I may use or disclose your medical information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or other person. Any disclosure would only be to someone able to help prevent the threat.

Military and Veterans:

 If you are a member of the military, I may release your medical information as required by the military authorities.

Workers Compensation:
 I may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

As Required by Law:
 I may disclose your health information when required to do so by federal, state, or local law.

Health Oversight Activities:
 I may use and disclose your medical information to health oversight agencies such as auditors, inspectors, and investigators. This may be necessary in order for the government to monitor the health care systems, government programs, and compliance with civil laws.

Lawsuits and Disputes:
 Unless specifically required by law or specifically ordered to do so by the court, I will not disclose your medical information in response to a subpoena or court/administrative order without your specific authorization.

Your Health Information Rights

You have the right to inspect and copy medical information that may be used to make decisions about your health care. This usually includes medical billing and records, but does NOT include psychotherapy notes. In order to inspect or copy medical information, a written request must be submitted to me. There may be a fee for copying and/or mailing the records.

Your request may be denied. If you are denied access to your medical information, you can ask for a review. I will ask another provider to review your request and the initial denial. I will comply with the outcome of the review.

You have the right to amend your medical information if you believe that it is incorrect or incomplete. You have the right to amend as long as the information was made at our facility. You must make the request in writing on my forms to me. The request must include the reason that supports your request. I may also deny your request if:

 The medical information was not created by me;

 The information requested is not part of the medical information kept by me;

 The information is not part of the information that you would be allowed to inspect or copy;

 My information is accurate and complete.

 Your request is inaccurate or incomplete.

You have a right to request an accounting of disclosures. Your request must be in writing. This request must state a specific time period, no longer than six years. The first request within a 12-month period is free. I reserve the right to charge you for copying any additional requests.

You have the right to request a restriction or to limit the medical information we may use or disclose for treatment, payment, or health care operations. You may also request a limit on the health information that we disclose to someone involved in your care, like a family member or friend.
WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST.

In order to request restrictions, you must do so in writing. The following information is needed in the request:

 What information you want to limit;

 Whether you want to limit use, disclosure, or both;

 To whom the limits apply.

You have the right to request that I communicate with you regarding medical matters in a certain way. For example, you could request that I contact you only at work or only at home. Such a request must be done in writing. I will accommodate all reasonable requests. The request must specify how or where you wish to be contacted.

You have a right to a paper copy of this Notice of Privacy Practices. You may ask for a copy at any time.

Changes to this notice: I reserve the right to change this notice at any time. I also reserve the right to make this change effective for medical information I already have regarding you and information I will receive about you in the future. I will post this notice in the waiting area or office. This notice will contain the effective date of the notice.

Complaints: I am committed to protecting your health information. Despite good faith efforts, there may be times when questions, concerns, or problems arise. If you have concerns or believe that I have violated your privacy rights, please contact me immediately. You may do so by filling out a complaint form, or you may contact me by phone or e-mail. You may identify yourself or remain anonymous. I take all concerns and complaints seriously and will investigate each one promptly. If I make a mistake, I will do what I can to correct it and take steps to prevent such mistakes from recurring in the future. If I did not make a mistake, I will provide you with an explanation. I will make every effort to complete my investigation within 30 days. Under no circumstances will I retaliate against you for expressing concerns or filing a complaint relating to your privacy rights. You also have the right to contact the department of Health and Human Services secretary if you believe your privacy rights have been violated.

Other Uses of Medical Information: Other uses and disclosures of your medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you give me permission to use or disclose your medical information, you can revoke it at any time with a written request.

Carl Grody, LISW-S, is a mental health provider and must follow the state laws regarding your medical information as well as the federal laws. If the state laws are stricter than the federal, then we will follow the state laws, and vice versa.

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