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Terms and Policy

SAMPLE HIPAA NOTICE OF PRIVACY PRACTICES
I. COMMITMENT TO YOUR PRIVACY: John Doe is dedicated to maintaining the privacy of your protected health information (PHI). PHI is information that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This Notice of Privacy Practices (“Notice”) is required by law to provide you with the legal duties and the privacy practices that John Doe maintains concerning your PHI. It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI. Please read carefully and discuss any questions or concerns with your therapist.

II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state law, John Doe is required to ensure that your PHI is kept private. This Notice explains when, why, and how John Doe would use and/or disclose your PHI. Use of PHI means when John Doe shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when John Doe releases, transfers, gives, or otherwise reveals it to a third party outside of the Institute. With some exceptions, John Doe may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, John Doe always legally required to follow the privacy practices described in this Notice.

III. CHANGES TO THIS NOTICE: The terms of this notice apply to all records containing your PHI that are created or retained by John Doe. Please note that John Doe reserves the right to revise or amend this Notice of Privacy Practices. Any revision or amendment will be effective for all of your records that John Doe has created or maintained in the past and for any of your records that John Doe may create or maintain in the future. John Doe will have a copy of the current Notice in the office in a visible location at all times, and you may request a copy of the most current Notice at any time. The date of the latest revision will always be listed at the end of John Doe Notice of Privacy Practices.

IV. HOW YOUR NAME MAY USE AND DISCLOSE YOUR PHI: John Doe will not use or disclose your PHI without your written authorization, except as described in this Notice or as described in the “Information, Authorization and Consent to Treatment” document. Below you will find the different categories of possible uses and disclosures with some examples.

1. For Treatment: John Doe may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If you are also seeing a psychiatrist for medication management, John Doe may disclose your PHI to her/him in order to coordinate your care. Except for in an emergency, John Doe will always ask for your authorization in writing prior to any such consultation.

2. For Health Care Operations: John Doe may disclose your PHI to facilitate the efficient and correct operation of its practice. Example: Quality control - John Doe may provide your PHI to its office personnel, accountants, practice consultants, attorneys and others to make sure that John Doe is in compliance with applicable practices and laws. It is John Doe practice to conceal all client names in such an event and maintain confidentiality. However, there is still a possibility that your PHI may audited for such purposes.

3. To Obtain Payment for Treatment: John Doe may use and disclose your PHI to bill and collect payment for the treatment and services John Doe provided you. Example: John Doe might send your PHI to your insurance company or managed health care plan, in order to get payment for the health care services that have been provided to you. John Doe could also provide your PHI to billing companies, claims processing companies, and others that process health care claims for John Doe office if either you or your insurance carrier are not able to stay current with your account. In this latter instance, John Doe will always do its best to reconcile this with you first prior to involving any outside agency.
4. Employees and Business Associates: There may be instances where services are provided to John Doe by an employee or through contracts with third-party “business associates.” Whenever an employee or business associate arrangement involves the use or disclosure of your PHI, John Doe will have a written contract that requires the employee or business associate to maintain the same high standards of safeguarding your privacy that is required of John Doe.


V. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES – YOUR NAME may use and/or disclose your PHI without your consent or authorization for the following reasons:

1. Law Enforcement: Subject to certain conditions, John Doe may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: John Doe may make a disclosure to the appropriate officials when a law requires John Doe to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
2. Lawsuits and Disputes: John Doe may disclose information about you to respond to a court or administrative order or a search warrant. John Doe may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. John Doe will only do this if efforts have been made to tell you about the request and you have been provided an opportunity to object or to obtain an appropriate court order protecting the information requested.
3. Public Health Risks: John Doe may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.
4. Food and Drug Administration (FDA): John Doe may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
5. Serious Threat to Health or Safety: John Doe may disclose your PHI if you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if John Doe determines in good faith that disclosure is necessary to prevent the threatened danger. Under these circumstances, John Doe may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public.
6. Minors: If you are a minor (under 18 years of age), John Doe may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.
7. Abuse and Neglect: John Doe may disclose PHI if mandated by Georgia child, elder, or dependent adult abuse and neglect reporting laws. Example: If John Doe has a reasonable suspicion of child abuse or neglect, John Doe will report this to the Georgia Department of Child and Family Services.
8. Coroners, Medical Examiners, and Funeral Directors: John Doe may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death or other duties as authorized by law. John Doe may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.
9. Communications with Family, Friends, or Others: John Doe may release your PHI to the person you named in your Durable Power of Attorney for Health Care (if you have one), to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you), or any other person you identify, relevant to that person’s involvement in your care or payment related to your care. In addition, John Doe may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition.
10. Military and Veterans: If you are a member of the armed forces, John Doe may release PHI about you as required by military command authorities. John Doe may also release PHI about foreign military personnel to the appropriate military authority.
11. National Security, Protective Services for the President, and Intelligence Activities: John Doe may release PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.
12. Correctional Institutions: If you are or become an inmate of a correctional institution, John Doe may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others
13. For Research Purposes: In certain limited circumstances, John Doe may use information you have provided for medical/psychological research, but only with your written authorization. The only circumstance where written authorization would not be required would be if the information you have provided could be completely disguised in such a manner that you could not be identified, directly or through any identifiers linked to you. The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of your information.
14. For Workers' Compensation Purposes: John Doe may provide PHI in order to comply with Workers' Compensation or similar programs established by law.
15. Appointment Reminders: John Doe is permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that you may need or that may be of interest to you.
16. Health Oversight Activities: John Doe may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs and compliance with laws. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess John Doe compliance with HIPAA regulations.
17. If Disclosure is Otherwise Specifically Required by Law.

VI. Other Uses and Disclosures Require Your Prior Written Authorization: In any other situation not covered by this notice, John Doe will ask for your written authorization before using or disclosing medical information about you. If you chose to authorize use or disclosure, you can later revoke that authorization by notifying John Doe in writing of your decision. You understand that John Doe is unable to take back any disclosures it has already made with your permission, John Doe will continue to comply with laws that require certain disclosures, and John Doe is required to retain records of the care that its therapists have provided to you.

VII. RIGHTS YOU HAVE REGARDING YOUR PHI:
1. The Right to See and Get Copies of Your PHI: In general, you have the right to see your PHI that is in John Doe possession, or to get copies of it; however, you must request it in writing. If John Doe does not have your PHI, but knows who does, you will be advised how you can get it. You will receive a response from John Doe within 30 days of receiving your written request. Under certain circumstances, John Doe may feel it must deny your request, but if it does, John Doe will give you, in writing, the reasons for the denial. John Doe will also explain your right to have its denial reviewed. If you ask for copies of your PHI, you will be charged not more than $.25 per page and the fees associated with supplies and postage. John Doe may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that John Doe limit how it uses and discloses your PHI. While John Doe will consider your request, it is not legally bound to agree. If John Doe does agree to your request, it will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that John Doe is legally required or permitted to make.
3. The Right to Choose How YOUR NAME Sends Your PHI to You: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). John Doe is obliged to agree to your request providing that it can give you the PHI, in the format you requested, without undue inconvenience.
4. The Right to Get a List of the Disclosures. You are entitled to a list of disclosures of your PHI that John Doe has made. The list will not include uses or disclosures to which you have specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel. The request must be in writing and state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003.
John Doe will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known), a description of the information disclosed, and the reason for the disclosure. John Doe will provide the list to you at no cost, unless you make more than one request in the same year, in which case it will charge you a reasonable sum based on a set fee for each additional request.
5. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that John Doe correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of John Doe receipt of your request. John Doe may deny your request, in writing, if it finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed, (c) not part of its records, or (d) written by someone other than John Doe denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and John Doe denial will be attached to any future disclosures of your PHI. If John Doe approves your request, it will make the change(s) to your PHI. Additionally, John Doe will tell you that the changes have been made and will advise all others who need to know about the change(s) to your PHI.
6. The Right to Get This Notice by Email: You have the right to get this notice by email. You have the right to request a paper copy of it as well.
7. Submit all Written Requests: Submit to John Doe Director and Privacy Officer at the address listed on top of page one of this document.

VIII. COMPLAINTS: If you are concerned your privacy rights may have been violated, or if you object to a decision John Doe made about access to your PHI, you are entitled to file a complaint. You may also send a written complaint to the Secretary of the Department of Health and Human Services Office of Civil Rights. John Doe will provide you with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.

Please discuss any questions or concerns with your therapist.
( Type Full Name )
Sample Late/Cancellation Policy
If a cancellation is less than 24 hours prior to the scheduled appointment, the full price of the session will be charged. If you are more than 20 minutes late, the session will be cancelled and you will be billed the entire cost of the session.
( Type Full Name )