Specializing in Emotional Transformation Therapy (ETT™)
Individuals and Couples Over 18 • LGBTQ Welcomed
NOTICE OF PRIVACY PRACTICES FORM
Effective Date: August 2016
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY the Practice AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact:
Linda Griffith, LCSW, DCSW 502-333-2193
Who Will Follow This Notice?
1. Linda Griffith, LCSW, DCSW, and
2. Linda Griffith, LCSW, DCSW’s subcontractors.
We understand that medical information about you and your health is personal and are committed to protecting this information. When you receive care from the Practice, a record of the care and services you receive is made. Typically, this record contains your treatment plan,
history, test results,and billing record. This record serves as a:
1. Basis for planning your treatment and services;
2. Means of communication among the health care providers involved in your care;
3. Means by which you or a third-party payor can verify that services billed were actually provided;
4. Source of information for public health officials; and
5. Tool for assessing and continually working to improve the care rendered.
This Notice tells you the ways we may use and disclose your Protected Health Information
(referred to herein as "medical information"). It also describes your rights and our obligations regarding the use and disclosure of medical information.
The Practice is required by law to:
1. Make every effort to maintain the privacy of your medical information;
2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;
3. Abide by the terms of this notice;
4. Notify you if we are unable to agree to a requested restriction;
5. Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations; and
6. Notify you, and the Department of Health & Human Services, of any unauthorized acquisition, access, use or disclosure of your unsecured medical information. We are required by law to notify you following a breach of unsecured protected health information. Unsecured medical information means medical information not secured by technology that renders the information unusable, unreadable, or indecipherable as required by law.
The Methods in Which We May Use and Disclose Medical Information about You
The following categories describe different ways we may use and disclose your medical information. The examples provided serve only as guidance and do not include every possible use or disclosure.
1. For Treatment. We will use and disclose your medical information to provide, coordinate, or manage your health care and any related service. For example, we may share your information with your primary care physician or other specialists to whom you are referred for follow-up care.
2. For Payment. We will use and disclose medical information about you so that the treatment and services you receive may be billed and payment may be collected from you, an insurance company, or a third party. For example, we may need to disclose your medical information to a health plan in order for the health plan to pay for the services rendered to you.
3. For Health Care Operations. We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the Practice in an efficient manner and provide that all patients receive quality care. For example, your
medical records and health information may be used in the evaluation of services, and the appropriateness and quality of health care treatment. In addition, medical records are audited for timely documentation and correct billing.
4. Appointment Reminders. We may use and disclose medical information in order to remind you of an appointment. For example, the Practice may provide a written or telephone reminder that your next appointment with the Practice is coming up.
5. Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the surgical outcome of all patients for whom one type of procedure is used to those for whom another procedure is used for the same condition. All research projects, however, are subject to a special approval process. Prior to using or disclosing any medical information, the project must be approved through this research approval process. We will ask for your specific authorization if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care.
6. As Required by Law. We will disclose medical information about you when required to do so by federal or Arizona laws or regulations.
7. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you to medical or law enforcement personnel when necessary to prevent a serious threat to your health and safety or the health and safety of another
8. Sale of Practice. We may use and disclose medical information about you to another health care facility or group of professionals in the sale, transfer, merger, or consolidation of our practice.
1. Organ and Tissue Donation. If you have formally indicated your desire to be an organ donor, we may release medical information to organizations that handle procurement of organ, eye, or tissue transplantations.
2. Military and Veterans. If you are a member of the armed forces, we may release medical
information about you as required by military command authorities.
3. Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
4. Qualified Personnel. We may disclose medical information for management audit, financial audit, or program evaluation, but the personnel may not directly or indirectly identify you in any report of the audit or evaluation, or otherwise disclose your identity in any manner.
5. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following activities:
a. To prevent or control disease, injury, or disability;
b. To report reactions to medications or problems with products;
c. To notify people of recalls of products they may be using;
d. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
e. To notify the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence.
f. All such disclosures will be made in accordance with the requirements of Arizona and federal laws and regulations.
6. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. Health oversight agencies include public and private agencies authorized by law to oversee the health care system. These oversight
activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws.
7. Lawsuits and Disputes. If you are involved in certain lawsuits or administrative disputes, we may disclose medical information about you in response to a court or administrative order.
8. Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
a. In response to a court order or subpoena; or
b. If the Practice determines there is a probability of imminent physical injury to you or another person, or immediate mental or emotional injury to you.
9. Coroners Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner when authorized by law (e.g., to identify a deceased person or determine the cause of death). We may also release medical information about patients to funeral directors.
10. Inmates. If you are an inmate of a correctional facility, we may release medical information about you to the correctional facility for the facility to provide you treatment.
Il. Other Uses or Disclosures. Any other use or disclosure of PHI will be made only upon your individual written authorization. You may revoke an authorization at any time provided that it is in writing and we have not already relied on the authorization.
12. Electronic Disclosure. We may use and disclose your medical information electronically.
For example, your medical information is maintained on an electronic health record. If another provider requests a copy of your medical record for treatment purposes, we may forward such record electronically.
DISCLOSURES REQUIRING AUTHORIZATION
1. Psychotherapy Notes. Psychotherapy notes are notes by a mental health professional that document or analyze the contents of a conversation during a private counseling session— or during a group, joint, or family counseling session. If these notes are maintained separate from the rest of your medical records, they can only be used and disclosed as follows. In general, psychotherapy notes may not be used or disclosed without your written authorization, except in the following circumstances.
Psychotherapy notes about you may be used and disclosed without your written authorization in the following situations:
a. The mental health professional who created the notes may use them to provide you with further treatment;
b. The mental health professional who created the notes may disclose them to students, trainees or practitioners in mental health who are learning under supervision to practice or improve their skills in group, joint, family, or individual counseling;
c. The mental health professional who created the notes may disclose them as necessary to defend himself or herself or the Practice in a legal proceeding initiated by you or your personal representative;
d. The mental health professional who created the notes may disclose them as required by law;
e. The mental health professional who created the notes may disclose the notes to appropriate government authorities when necessary to avert a serious and imminen tthreat to the health or safety of you or another person;
f. The mental health professional who created the notes may disclose them to the United States Department of Health and Human Services when that agency requests them in order to investigate the mental health professional's compliance,or the Practice's compliance, with Federal privacy and confidentiality laws and
g. The mental health professional who created the notes may disclose them to medical examiners and coroners, if necessary, to determine your cause of death.
All other uses and disclosures of psychotherapy notes require your written authorization. You have the right to revoke such authorization in writing.
2. Marketing. Marketing generally includes a communication made to describe a health related product or service that may encourage you to purchase or use the product or service. For example, marketing includes communications to you about new state-of-the-art equipment if the equipment manufacturer pays us to send the communication to you. We will obtain your written authorization to use and disclose PHI for marketing purposes unless the communication is made face-to-face, involves a promotional gift of
nominal value, or otherwise permitted by law. All other uses and disclosures of your information for marketing purposes requires your
written authorization. You have the right to revoke such authorization in writing.
3. Sale of your Medical Information. the Practice will not sell your medical information for marketing purposes. However, there are instances in which the Practice will sell your PHI. For example, should the Practice merge or the practice is sold to another group,
your medical record may be part of the asset transfer. Any other Sale of Protected Health Information requires your written authorization. You have the right to revoke such authorization in writing.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information collected and maintained about you:
1. Right to Inspect and Copy. The right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records.To inspect and copy medical information that may be used to make decisions about you,
you must submit your request in writing to the Privacy Officer for the Practice. If you request a copy of the information, the Practice may charge a fee for the costs of copying, mailing, or summarizing your records.The Practice may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Practice will
review your request and denial. The person conducting the review will not be the person who denied your request. the Practice will comply with the outcome of the review.
2. Right to Amend. If you feel that medical information maintained about you is incorrect or incomplete, you may ask the Practice to amend the information. You have the right to request an amendment for as long as the information is kept by the Practice.To request an amendment, your request must be made in writing and submitted to the Practice. In addition, you must provide a reason that supports your request. The Practice may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, the Practice may deny your request
if you ask us to amend information that:
• Was not created by the Practice, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the medical information kept by the Practice;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.
3. Right to an Accounting of Disclosures. To request an "accounting of disclosures." This is a list of the disclosures made of your medical information for purposes other than treatment, payment, or health care operations.To request this list you must submit your request in writing to (name and title) Your request must state a time period, which may not be longer than six (6) years. Your request
should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists within the 12-month period, you may be charged for the cost of providing the list. the Practice will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
4. Right to Request Restrictions. To request a restriction or limitation on the medical information the Practice uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information the Practice discloses about you to someone who is involved in your care or the payment for your care. The Practice is not required to agree to your request, unless the request pertains solely to a healthcare item or service for which the Practice has been paid out of pocket in full
and: (i) the restriction pertains to payment or a healthcare operation and (ii) the disclosure is not otherwise required by law. Should the Practice agree to your request,the Practice will comply with your request unless the information is needed to provide
you emergency treatment. To request restrictions you must make your request in writing to the Practice. In your request, you may indicate: (1) what information you want to limit; (2) whether you want to limit the Practice's use and/or disclosure; and (3) to whom you want the limits to apply.
5. Right to Request Confidential Communications. To request that the Practice communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that the Practice contact you only at work or by mail.To request that the Practice communicate in a certain manner, you must make your
request in writing to the Privacy Officer. You do not have to state a reason for your request. the Practice will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
6. Right to Revoke an Authorization. There are certain types of uses or disclosures that require your express authorization. For example, the Practice may not sell your
information to a third party for marketing purposes without first obtaining your authorization. If you provide authorization for a particular use or disclosure of your medical information, you may revoke such authorization in writing by contacting Linda Griffith, LCSW, DCSW at 10020 East Moccasin Place, Tucson AZ 85749 or email@example.com . We will honor your revocation except
to the extent that we have already taken action in reliance of the specific authorization.
7. Right to Receive a Copy of this Document. You have a right to obtain a paper copy of this document upon request.
CHANGES TO THIS NOTICE
We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will post the amended Notice of
Privacy Practices in our office and on our website. You may request that a copy be provided to you by contacting the Privacy Officer.
If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Office for Civil Rights, U.S. Department of Health and Human Services. To file a complaint with the Practice, contact the Privacy Officer at 520-333-2193. Your complaint must be filed within 180 days of when you knew or should have known that the act occurred. The address for the Office of Civil Rights is:
Secretary of Health & Human Services
Region IX, Office for Civil Rights
U.S Department of Health and Human Services
90 Seventh Street Federal Building, Suite 5-100
San Francisco CA 94103
All complaints should be submitted in writing.
You will NOT be penalized for filing a complaint.
Licensed in Arizona for the practice of clinical social work