Andrea Stuck, LISW S
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. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as, Protected Health information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Amy new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purposes of providing, coordinating, and managing your health care treatment and related services. This includes consultation with clinical supervisors, professional peer reviewers or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. Examples of payment related activities include 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, undertaking utilization review activities, and preparing a bill to send to you or the person responsible for your payment. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.
- We may release your personal health information for any purpose required by law,
- We may release your personal health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigators
- We may release your personal health information as required by law if we suspect child abuse or neglect, we may also release your personal health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
- We may release your personal health information to the Food and drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
- We may release your personal health information to your employer when we have provided health care to you at the request of your employer to determine workplace related illness or injury; in most cases you will receive notice that information is disclosed to your employer
- We may release your personal health information if by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings,
- We may release your personal health information if required to do so by a court or administratively ordered subpoena or discovery request; in most cases you will have notice of such release *We may release your personal health information to law enforcement officials as required by law to report wounds, injuries and crimes;
- We may release your personal health information to coroners and or funeral directors consistent with the law
- We may release your personal health information if necessary to arrange an organ or tissue donation from you or a transplant for you;
- We may release your personal health information to those likely to be affected if there is a serious threat to your health or safety or the health or safety of another person;
- We may release your personal health information if you are a member of the military as required by armed forces services; we may also release your personal health information if necessary for national security or intelligence activities; and
- We may release your personal health information to workers’ compensation agencies if necessary for your workers’ compensation benefits.
Ohio law requires that we obtain a written authorization from you in many instances before disclosing the performance or results of an HIV test or diagnoses of AIDS or AIDS related condition; before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program; before disclosing information about mental health services you may have received.
Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked any time in writing. Please note that the revocation does not pertain to information disclosed in reliance on the authorization prior to the date of the revocation.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Andrea Stuck, LISW at 870 High Street, Suite 14, Worthington, Ohio 43085:
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost based fee for copies.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12 month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
Right to a Copy of this Notice. You have the right to a copy of this notice.
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer, Andrea Stuck, LISW at 870 High Street, Suite 14, Worthington, Ohio 43085 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing, a complaint
The effective date of this Notice is April, 2003
NATIONAL ASSOCIATION OF SOCIAL WORKERS DOCUMENT D2
© Popovits & Robinson, P.C. 2003
Website Privacy Practices
Email Addresses. We collect email addresses for the purpose of sending an Email newsletter, order information and other downloadable information shared for free. We do not share, sell or give your Email address to anyone. Those on the newsletter list may also be sent information pertaining to workshops or other educational information concerning Stuck? practice.
Collected Information. When you sign up for information, services, or products at andystuck.com, we may collect personal information from you including your name, e-mail address, billing address (where applicable), phone number, security question (and answer), credit card or other payment information, and a password.
We may also collect the URL from which you linked into our site, your IP address, and your browser type and version, all of which are collected in an anonymous manner without being linked to any of your personal information.
Use Of Customer Information. Customer privacy is something we take very seriously andystuck.com. We do not sell or disseminate (except in cases where required to by law by law enforcement agencies) the personal information of our customers to any parties outside of andystuck.com.
How Does The Site Use Personally Identifiable Information?
We use Personally Identifiable Information to customize the Site, to make appropriate service offerings, and to fulfill buying and selling requests on the Site. We may email Visitors and Authorized Customers about research or purchase and selling opportunities on the Site or information related to the subject matter of the Site. We may also use Personally Identifiable Information to contact Visitors and Authorized Customers in response to specific inquiries, or to provide requested information.
How Is Personally Identifiable Information Stored?
Personally Identifiable Information collected by andystuck.com is securely stored and is not accessible to third parties or employees of andystuck.com except for use as indicated above.
What Choices Are Available To Visitors Regarding Collection, Use And Distribution Of The Information?
Visitors and Authorized Customers may opt out of receiving information from or being contacted by us by responding to emails as instructed, or by contacting us at email@example.com .
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