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.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION:
Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information often referred to as your health or medical record, serves as a basis for planning your care as well as a legal document describing the care you received. This also helps verify to a third-party payer that the services billed were actually provided. Understanding what is in your record and how health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information and make more informed decision when authorizing disclosures to others.
YOUR HEALTH INFORMATION RIGHTS:
Although your health record is the physical property of the healthcare provider or facility that compiled it, the information belongs to you. This includes the right to inspect and obtain a copy of your health record. You may exercise this right by requesting the Consumer Request for Access and/or Copy of Protected Health Information form from your local clinic. We have 30 days following receipt of the request to respond (60 days if your record is not accessible on site). If you request a copy of your record, we may charge a fee for the cost of copying and postage (if applicable). Access to certain components of your protected health information (PHI) may be denied if a licensed health care professional has determined, in the exercise of professional judgment, that access may endanger the life or safety of you or another person. If access is denied, we will provide you with a timely, written denial explaining the basis for the denial and your right to file a complaint and how to exercise those rights.
You also have a right to amend your health record if you believe incorrect information has been documented in your record. You may exercise this right by requesting the Consumer Request for Amendment of Protected Health Information form from you local clinic. Requests must contain a reason to support an amendment. In certain circumstances, we do reserve the right to deny such amendments. For example, if we believe that the information in your record is accurate, or if the information was not created by an employee or business associate of Blue Ridge Counseling/Serenity Counseling & Consulting Service/Kelly Consulting Service/Susan R. Doub, MA, LPC. We have 60 days upon receipt of such a request to render a decision. If we deny an amendment, we will notify you in writing the reason for the denial and your right to appeal such a decision and how to exercise this right.
You have a right to receive confidential communication of your protected health information such as requesting that we not mail correspondence to your home address or leave messages on your answering machine. You may exercise this right by requesting the Consumer Request for An Alternative Method of Contact form from your local clinic. We are not required to agree to your request if it is deemed “unreasonable”.
You may also obtain an accounting (which means a detailed listing) of disclosures of your health information that we have made for the previous six years. The accounting will not include several types of disclosures including disclosures for treatment, payment, healthcare operations or disclosures made pursuant to a valid authorization. It will also not include disclosures made prior to July 1, 2005. You may exercise this right by requesting the Consumer Request for an Accounting of Disclosures form from your local clinic. We have 60 days to respond to such a request. If we cannot respond within 60 days, we will provide you with a written statement outlining the reasons for the delay and the date by which the information will be provided. The extension time can be for no more than 30 days. You may request that this report be made to you either orally or in written format. The first accounting in a 12-month period must be provided to you without a charge. A reasonable cost-based fee may be charged for any subsequent accountings within a 12-month period. If you request more than one accounting of disclosures within a 12-month period, you will be informed in advance of the fee and provided an opportunity to withdraw or modify the request in order to reduce the fee.
You also have the right to request that we limit the use and disclosure of medical information about you for treatment, payment and health care operations. You may exercise this right by requesting the Consumer Request for Restriction of Protected Health Information form from you local clinic. We are not required to agree to your request. If we do agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment). In addition, we may cancel a restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.
You have the right to revoke your authorization to use or disclose health information except to the extent that action has already been taken. Requests must be made in writing.
In the event you require assistance with exercising any of the above rights, you must notify your treating clinician and he/she will arrange for assistance.
Blue Ridge Counseling/Serenity Counseling & Consulting Service/Kelly Consulting Service/Susan R. Doub, MA, LPC is required to maintain the privacy of your health information and provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. We must also abide by the terms of this notice, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations and notify you if we are unable to agree to a requested restriction. We reserve the right to change our Notice of Privacy Practices and to apply these changes retroactively. Should our information practices change, we will supply you with a revised copy upon your next scheduled visit. We will not use or disclose your health information without your authorization, except as described in this notice.
EXAMPLES OF DISCLOSURES:
FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS:
We will use your health information for treatment. For example, information obtained about you by a counselor or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Members of your healthcare team will also record treatment goals that you established and interventions used to help you progress towards reaching these goals. Your counselor will also record information pertaining to medications that have prescribed to you as well as your response to these medications.
We will use your health information for payment. For example, a bill will be sent to you and/or a third-party payer. Information on or accompanying the bill may include information that identifies you, as well as your diagnosis, your treating clinician and the type of services you have received.
We may release your health information to business associates. There are some services provided in this agency through contracts with business associates who are not employees of Blue Ridge Counseling/ Serenity Counseling & Consulting Service/Kelly Consulting Service/Susan R. Doub, MA, LPC. We may disclose your health information to our business associates so they can perform the job we’ve asked them to do. To protect your health information, however, they too are required to appropriately safeguard your information. Examples of business associates may include but is not limited to: medical transcription services, software/hardware vendors and legal services.
We may use or disclose certain protected health information (PHI) without written authorization in limited circumstances such as: those required by law; public health activities, health oversight activities, disclosures about abuse, neglect or domestic violence; judicial and administrative proceedings; law enforcement purposes; and certain government functions. *Please note: this is NOT an exhaustive list and is not limited to the examples listed below.
Examples of uses and disclosures required by law: A responsible clinician can disclose PHI when, in his/her opinion, there is an imminent danger to the health or safety of the consumer or another individual. In these circumstances, we are required by law to take action to ensure that no harm occurs to the consumer or someone else.
Examples of uses and disclosures for public health activities: We may disclose PHI about you for public health activities. For example, activities related to investigating exposure to communicable diseases or reporting child abuse and neglect.
Examples of uses and disclosures for health oversight activities: We may disclose medical information about you to a health oversight agency. For example, a government agency may request information from us while they are investigating possible insurance fraud.
Examples of uses and disclosures about abuse, neglect or domestic violence: We may disclose PHI to a government authority that is authorized by law to conduct an investigation regarding abuse and/or neglect. For example, if you are an adult and we reasonably believe that you may be a victim of abuse, neglect or domestic violence.
Examples of uses and disclosures for law enforcement purposes: We can disclose PHI without an authorization for specific law enforcement purposes. For example, we may disclose limited PHI without consumer authorization in response to law enforcement official’s request for such information for the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
Examples of uses and disclosures for governmental functions: We may use or disclose PHI for certain governmental functions. For example, we may disclose information about you for national security and intelligence activities.
FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions or would like additional information, you may speak to your provider or contact the Facility Director at 1-336-677-3991. If you believe your privacy rights have been violated, you can file a complaint with the Facility Director or with the Secretary of the Department of Health and Human Services at 1-866-627-7748. Complaints must be filed within 180 days of when you knew or should have known that the act complained of occurred. There will be no retaliation against you for filing a complaint.