Notice of Holistic Psychiatric Healths Privacy Practices:


  This notice describes how information about you may be used and disclosed and how you may getaccess to this information. Review carefully and entirely.


Each time you visit a provider, a record of your visit is made. Typically, this record contains yoursymptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, andbilling-related information. This Notice applies to all of the records of your care generated by yourprovider.

  Our Responsibilities

   Holistic Psychiatric Health is required by law to maintain the privacy of your health information and toprovide you with a description of our legal duties and privacy practices regarding your healthinformation. We will provide you with a copy of this notice that we request you acknowledge with yoursignature. We are required by law to abide by the terms of this Notice and notify you if we makechanges to this Notice, which may be at any time. Changes to the Notice will apply to your healthinformation that we already maintain as well as new information received after the change occurs. If wechange our Notice, it will be posted in the office. You may also request that a revised Notice be sent toyou in the mail or you may ask for one at your next appointment or appropriate visit. This Notice willalso serve to advise you as to your rights with regard to your health information.

  How We May Use and Disclose Health Information About You

   The following categories describe examples of the way we use and disclose medical information:

  For Treatment: We may use health information about you to provide, coordinate and manage yourtreatment or services. We may disclose health information about you to other doctors, nurses,technicians (e.g. clinical laboratories or imaging companies), medical students, or other personnel whoare involved in your care. We may communicate your information either orally or in writing by mail orfacsimile. We may also provide a subsequent healthcare provider with copies of various reports thatshould assist him or her in treating you. For example, your health information may be provided to aphysician to whom you have been referred so as to ensure that the physician has appropriateinformation regarding your previous treatment and diagnosis.

  For Payment: We may use and disclose health information about your treatment and services to bill andcollect payment from you, your insurance company or a third party payer. For example, we may need togive your insurance company information before it approves or pays for the health care services werecommend for you.

  For Health Care Operations: We may use or disclose, as needed, your health information in order tosupport our business activities. These activities may include, but are not limited to quality assessmentactivities, employee review activities, licensing, legal advice, accounting support, information systemssupport and conducting or arranging for other business activities. In addition, we may also call you byname in the waiting room when your provider is ready to see you. We may use or disclose yourprotected health information, as necessary, to contact you to remind you of your appointment bytelephone call, text messaging, email or reminder card via mail.

  Business Associates: There are some services provided in our organization through contracts withbusiness associates. Examples include collection agencies, medical records storage, and softwarevendor. When these services are contracted, we may disclose your health information to our businessassociate so that they can perform the job that we have asked them to do and bill you or your thirdparty payer for services rendered. To protect your health information, however, we require the businessassociate to appropriately safeguard your information through a written contract.

  Other Permitted and Required Uses and Disclosures That May Be Made with Your Consent,Authorization or Opportunity to Object: We also may use and disclose your health information as setforth below. You have the opportunity to agree or object to the use or disclosure of all or part of yourhealth information in these instances. If you are not present or able to agree or object to the use ordisclosure of the health information (such as in an emergency situation or if unconscious), then yourclinician may, using professional judgment, determine whether the disclosure is in your best interest. Inthis case, only the information that is relevant to your health care will be disclosed. 


  Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release healthinformation about you to a friend or family member who is involved in your health care or who helps topay for your care. In addition, we may disclose health information about you to an entity assisting in adisaster relief effort so that your family can be notified about your condition, status and location. If youhave given someone medical power of attorney or if someone is your legal guardian, that person mayexercise your rights and make choices about your health information. 


  Future Communications: We may communicate to you via newsletters, mailings or other meansregarding treatment options, information on health-related benefits or services, to remind you that youhave an appointment, or other community based initiatives or activities in which our facility isparticipating. If you are not interested in receiving these materials, please inform the office. 


  Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization orOpportunity to Object: We may use or disclose your health information in the following situationswithout your authorization or without providing you with an opportunity to object. These situations, As required by law, include but are not limited to the following types of entities: 


  Food and Drug Administration; Public Health or Legal Authorities charged with preventing or controllingdisease, Injury or disability; Help with product recalls; Reporting adverse reactions to medications;Preventing or reducing a serious threat to anyone’s health or safety; Comply with law; CorrectionalInstitutions; Workers Compensation Agents; Organ and Tissue Donation Organizations; MilitaryCommand Authorities; Health Oversight Agencies; Funeral Directors, Coroners and Medical Directors;National Security and Intelligence Agencies; Protective Services for the President and Others; Authoritythat receives reports on abuse, neglect and domestic violence; Law Enforcement/Legal Proceedings: Wemay disclose health information for law enforcement purposes as required by law or in response to avalid subpoena; State-Specific Requirements: Many states have requirements for reporting includingpopulation-based activities relating to improving health or reducing health care costs. You may ask for alist of the times we’ve shared your health information for 6 years prior to the date you ask, as well aswho we shared it with and why.

Your Health Information Rights: Although your health record is the physical property of Holistic Psychiatric Health, that compiled it, you have the right to:  

  Inspect and Copy: You have the right to inspect and copy health information that may be used to makedecisions about your care. We ask that you submit these requests in writing. We may deny your requestto inspect and copy in certain very limited circumstances. Requests for access to and copies of yourhealth information must be submitted to Holistic Psychiatric Health in writing. The practice may chargeup to $20.00 per hour for the clerical time and 25 cents per page for copies of the medical record. Requestsare usually honored within 30 days.

  Amend: If you feel that the health information we have about you is incorrect or incomplete, you may askus to amend the information by submitting a request in writing. You have the right to request anamendment for as long as we keep the information. We may deny your request for an amendment andif this occurs, you will be notified of the reason for the denial.


  Request Restrictions: You have the right to request a restriction or limitation on the health informationwe use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in yourcare or the payment for your care, like a family member or friend. We ask that you submit theserequests in writing. We are not required to agree to your request. If we do agree, we will comply withyour request unless the information is needed to provide you with emergency treatment. If you pay outof pocket in full for a service or health care item you can ask us not to share that information for thepurpose of payment or our operations with your health insurer. We will say “yes” unless a law requiresus to share that information.  

  Instances we will not share your information unless you give written permission to do so: Marketing purposes, sale of your information, sharing most psychotherapy notes, fundraising.

  Request Confidential Communications: You have the right to request that we communicate with youabout health matters in a certain way. We will agree to the request to the extent that it is reasonable forus to do so. For example, you can ask that we use an alternative address for billing purposes. We askthat you submit these requests in writing.

  A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To exercise any of your rights, please obtain the required forms and submit your request in writing. 


  Complaints: If you feel your rights were violated, you can complain by contacting us. You may file acomplaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will notretaliate against you for filing a complaint. 


  Health Insurance Portability and Accountability Act of 1996   

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