Family Consultation Service
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 IT CAREFULLY.
For purposes
of clarification and understandability, this document is written in the first
person as it pertains to your particular therapist as an independent contractor
of Family Consultation Service.
II. I
HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)
I am legally required
to protect the privacy of your PHI, which includes information that can be used
to identify you that I've created or received about your past, present, or future
health or condition, the provision of health care to you, or the payment of
this health care. I must provide you with this Notice about my privacy practices',
and such Notice must explain how, when, and why I will "use" and "disclose"
your PHI. A "use" of PHI occurs when I share, examine, utilize, apply, or analyze
such information within my practice; PHI is "disclosed" when it is released,
transferred, has been given to, or is otherwise divulged to a third party outside
of my practice. With some exceptions, I may nor use or disclose any more
of your PHI than is necessary to accomplish the purpose for which the use or
disclosure is made. And, I am legally required to follow the privacy practices
described in this Notice.
However, I reserve
the right to change the terms of this Notice and my privacy policies at any
time. Any changes will apply to PHI on file with me already. Before I make any
important changes to my policies, I will promptly change this Notice and post
a new copy of it in my office and on my website (if applicable). You can also
request a copy of this Notice from me, or you can view a copy of it in my office
or at my website, which is located at FCSchristiancounseling.com.
III. HOW
I MAY USE AND DISCLOSE YOUR PHI.
I will use and
disclose your PHI for many different reasons. For some of these uses or disclosures,
I will need your prior authorization; for others, however, I do not. Listed
below are the different categories of my uses and disclosures along with some
examples of each category.
A. Uses
and Disclosures Relating to Treatment, Payment, or Health Care Operations Do
Not Require Your Prior Written Consent. I can use and disclose your
PHI without your consent for the following reasons:
- For
treatment. I can disclose your PHI to physicians, psychiatrists,
psychologists, and other licensed health care providers who provide you
with health care services or are involved in your care. For example, if
you're being treated by a psychiatrist, I can disclose your PHI to your
psychiatrist in order to coordinate your care.
- To
obtain payment for treatment. I can use and disclose your PHI to
bill and collect payment for the treatment and services provided by me to
you. For example, I might send your PHI to your insurance company or health
plan to get paid for the health care services that I have provided to you.
I may also provide your PHI to my business associates, such as billing companies,
claims processing companies, and others that process my health care claims.
- For
health care operations. I can disclose your PHI to operate my practice.
For example, I might use your PHI to evaluate the quality of health care
services that you received or to evaluate the performance of the health
care professionals who provided such services to you. I may also provide
your PHI to our accountants, attorneys, consultants, and others to make
sure I'm complying with applicable laws.
- Other
disclosures. I may also disclose your PHI to others without your
consent in certain situations. For example, your consent isn't required
if you need emergency treatment, as long as I try to get your consent after
treatment is rendered, or if I try to get your consent but you are unable
to communicate with me (for example, if you are unconscious or in severe
pain) and I think that you would consent to such treatment if you were able
to do so.
- Certain
Uses and Disclosures Do Not Require Your Consent. I can use and disclose
your PHI without your consent or authorization for the following reasons:
- When
disclosure is required by federal, state or local law; judicial or administrative
proceedings; or, law enforcement. For example, I may make a disclosure
to applicable officials when a law requires me to report information to
government agencies and law enforcement personnel about victims of abuse
or neglect; or when ordered in a judicial or administrative proceeding.
- For
public health activities. For example, I may have to report information
about you to the county coroner.
- For
health oversight activities. For example, I may have to provide
information to assist the government when it conducts an investigation or
inspection of a health care provider or organization.
- For
research purposes. In certain circumstances, I may provide PHI
in order to conduct medical research.
- To
avoid harm. In order to avoid a serious threat to the health or
safety of a person or the public, I may provide PHI to law enforcement personnel
or persons able to prevent or lessen such harm.
- For
specific government functions. I may disclose PHI of military personnel
and veterans in certain situations. And I may disclose PHI for national
security purposes, such as protecting the President of the United States
or conducting intelligence operations.
- For
workers' compensation purposes. I may provide PHI in order to comply
with workers' compensation laws.
- Appointment
reminders and health related benefits or services. I may use PHI
to provide appointment reminders or give you information about treatment
alternatives, or other health care services or benefits I offer.
- Certain Uses
and Disclosures Require You to Have the Opportunity to Object.
- Disclosures
to family, friends, or others. I may provide your PHI to a family member,
friend, or other person that you indicate is involved in your care or the
payment for your health care, unless you object in whole or in part. The
opportunity to consent may be obtained retroactively in emergency situations.
- Other
Uses and Disclosures Require Your Prior Written Authorization. In
any other situation not described in sections III A, B, and C above, I will
ask for your written authorization before using or disclosing any of your
PHI. If you choose to sign an authorization to disclose your PHI, you can
later revoke such authorization in writing to stop any future uses and disclosures
(to the extent that I haven't taken any action in reliance on such authorization)
of your PHI by me.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI You have the following
rights with respect to your PHI:
- The
Right to Request Limits on Uses and Disclosures of Your PHI. You
have the right to ask that I limit how I use and disclose your PHI. I will
consider your request, but I am nor legally required to accept it. If I accept
your request, I will put any limits in writing and abide by them except in
emergency situations. You may not limit the uses and disclosures that I am
legally required or allowed to make.
- The
Right to Choose How I Send PHI to You. You have the right to ask
that I send information to you to at an alternate address (for example, sending
information to your work address rather than your home address) or by alternate
means (for example, e-mail instead of regular mail) I must agree to your request
so long as I can easily provide the PHI to you in the format you requested.
- The
Right to See and Get Copies of Your PHI. In most cases, you have
the right to look at or get copies of your PHI that I have, bur you must make
the request in writing. If I don't have your PHI but I know who does, I will
tell you how to get it. I will respond to you within 30 days of receiving
your written request. In certain situations, I may deny your request. If do,
I will tell you, in writing, my reasons for the denial and explain your right
to have my denial reviewed.
If you request
copies of your PHI, I will charge you not more than $.25 for each page. Instead
of providing the PHI you requested, I may provide you with a summary or explanation
of the PHI as long as you agree to that and to the cost in advance.
- The
Right to Get a List of the Disclosures I Have Made. You have the
right to get a list of instances in which I have disclosed your PHI. The list
will not include uses or disclosures that you have already consented to, such
as those made for treatment, payment, or health care operations, directly
to you, or to your family. The list also won't include uses and disclosures
made for national security purposes, to corrections or law enforcement personnel,
or disclosures made before April 15, 2003.
I will respond
to your request for an accounting of disclosures within 60 days of receiving
your request. The list I will give you will include disclosures made in the
last six years unless you request a shorter time. The list will include the
date of the disclosure, to whom PHI was disclosed (including their address,
if known), a description of the information disclosed, and the reason for the
disclosure. I will provide the list to you at no charge, but if you make more
than one request in the same year, I will charge you a reasonable cost-based
fee for each additional request.
- The
Right to Correct or Update Your PHI. If you believe that there is
a mistake in your PHI or that a piece of important information is missing,
you have the right to request that I correct the existing information or add
the missing information. You must provide the request and your reason for
the request in writing. I will respond within 60 days of receiving your request
to correct or update your PHI. I may deny your request in writing if the PHI
is (i) correct and complete, (ii) not created by me, (iii) not allowed to
be disclosed, or (iv) not part of my records. My written denial will state
the reasons for the denial and explain your right to file a written statement
of disagreement with the denial. If you don't file one, you have the right
to request that your request and my denial be attached to all future disclosures
of your PHI. If I approve your request, I will make the change to your PHI,
tell you that I have done it, and tell others that need to know about the
change to your PHI.
- The
Right to Get This Notice by E-Mail. You have the right to get a copy
of this notice bye-mail. Even if you have agreed to receive notice via e-mail,
you also have the right to request a paper copy of it.
V. HOW
TO complain ABOUT MY PRIVACY PRACTICES If you think that I may have
violated your privacy rights, or you disagree with a decision I made about access
to your PHI, you may file a complaint with the person listed in Section VI below.
You also may send a written complaint to the Secretary of the Department of
Health and Human Services at 200 Independence Avenue SW., Washington, D.C. 20201.
I will take no retaliatory action against you if you file a complaint about
my privacy practices.
VI. PERSON
TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO complain ABOUT MY PRIVACY
PRACTICESIf you have any questions about this notice or any complaints
about my privacy practices, or would like to know how to file a complaint with
the Secretary of the Department of Health and Human Services, please contact
me at: Family Consultation Service, 3838 Camino del Rio North Suite 162, San
Diego CA 92108, 619.280.3430.
VII. EFFECTIVE
DATE OF THIS NOTICE This notice went into effect on April 14, 2003.
Family
Consultation Service
3838
Camino del Rio North, Suite 162
San
Diego, California 92108
619.280.3430
www.FCSchristiancounseling.com
copies
of this Notice available at your first appointment or upon request from our
office.