THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. Your therapist maintains a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all records related to your care at this mental health practice and tells you about the ways in which we may use and disclose health information about you. It also describes your rights to the health information we keep about you and describes certain obligations we have regarding the use and disclosure of your health information.

• We are required by law to maintain the privacy and security of your PHI.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described in this Notice unless you provide written Authorization. You have the right to revoke that Authorization at any time.  

 

PRIVACY RELATED TO PROFESSIONAL RECORDS

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), our providers may keep your PHI in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to state law, psychological test data are not part of a client’s Clinical Record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your therapist, or have them forwarded to another mental health professional, so you can discuss the contents. If we refuse your request for access to your Clinical Record, you have a right to have our decision reviewed by another mental health professional, which we will discuss with you upon your request. 

 

Your therapist may also keep a set of Psychotherapy Notes. Psychotherapy Notes are for the therapist’s own use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, your doctor’s analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. Because Psychotherapy Notes are meant to be used by your therapist alone, they are subject to a greater degree of privacy and confidentiality and are generally not disclosed for other purposes. Under HIPAA laws, clients do not have a right to access Psychotherapy Notes. You may request access. However, your therapist is not obligated to provide these.

 

HOW WE MAY USE AND DISCLOSE YOUR PHI

We use and disclose your PHI for many different reasons. For some of these uses or disclosures, we will need your prior authorization. For others, we do not. Listed below are categories related to our uses and disclosures along with some examples. 

 

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations

In most situations, we can only release information about your services to others if you sign a Release of Information Form that meets HIPAA-related legal requirements. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: 

1. For Treatment. Disclosures for treatment purposes are not limited to the minimum necessary standard. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another. We 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, we can disclose your PHI to your psychiatrist in order to coordinate your care.

2. To Obtain Payment for Services. We can use and disclose your PHI to bill and collect payment for treatment and services provided. For example, we may provide your PHI to business associates, such as billing companies, claims processing companies, or others that process health care claims. 

3. For Health Care Operations. We can disclose your PHI to operate our practice. For example, we 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. We may also provide your PHI to our accountants, attorneys, consultants, and others to make sure we are complying with applicable laws.

 

Uses and Disclosures that Do Not Require Your Authorization

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

1. For public health activities, including reporting suspected child, elder, or dependent adult abuse, neglect, or domestic violence, or preventing or reducing a serious threat to anyone’s health or safety.

2. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

3. To coroners or medical examiners, when such individuals are performing duties authorized by law.

4. For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

5. For law enforcement purposes, including reporting crimes occurring on our premises.

6. For health oversight activities, including audits and investigations.

7. Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.

8. For judicial and administrative proceedings, including responding to a court order, administrative order, or subpoena, although our preference is to obtain an Authorization from you before doing so and we make every effort to limit these disclosures.

 

Uses and Disclosures that Require You to Have the Opportunity to Object

Disclosures to family, friends, or others. We 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.

 

Uses and Disclosures that Require Your Prior Written Authorization

In any other situation not described above, we 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 we haven’t taken any action in reliance on such authorization).

 

Uses and Disclosures that Are Not Relevant to This Practice

Tailored Therapy & Counseling does not use or disclose PHI for marketing purposes, sale, fundraising, or research.

 

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

1. The Right to Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request. We may charge a reasonable, cost-based fee for doing so.

2. 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 from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address, and we will agree to all reasonable requests.

4. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care. In addition, if you pay for a service out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI up to six years prior to the date you make the request. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include all disclosures except for those related to treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide the list to you at no charge, but if you make more than one request within 12 months, we will charge you a reasonable cost-based fee for each additional request.

6. The Right to Get a Copy of this Notice. You have the right get a paper or electronic copy of this Notice. Even if you agreed to receive this Notice via e-mail, you have the right to request a paper copy.

7. The Right to Choose Someone to Act on Your Behalf. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

8. The Right to File a Complaint. If you feel your rights have been violated, you can file a complaint with Dr. Katarina Ament, the owner of Tailored Therapy & Counseling, PLLC, using the contact information provided on page 1 of this Notice. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

 

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

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EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on June 21, 2023.​

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