NOTICE OF PRIVACY PRACTICES

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The Counseling Shop 

11224 86th Ave. N  

Maple Grove, MN 55369 

Phone:  (763) 400-7075      

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 THIS NOTICE CAREFULLY. 

Your health record contains personal information about you and your health.  This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”).  This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law.  It also describes your rights regarding how you may gain access to and control your PHI.   

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.  We are required to abide by the terms of this Notice of Privacy Practices.  We reserve the right to change the terms of our Notice of Privacy Practices at any time.  Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time.  We will provide you with a copy of the revised Notice of Privacy Practices at your next appointment. 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

For Treatment.  Your information may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services.  This includes consultation with specialists to obtain an opinion.  We may disclose information to any other consultant only with your authorization. 

For Payment.  We may use or disclose your information so that we can receive payment for the treatment services provided to you.  This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.  If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of your information necessary for purposes of collection. 

For Health Care Operations.  We may use or disclose, as needed, your information in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities.  For example, we may share your information with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your information.   

Required by Law.  Under the law, we must make disclosures of your information to you upon your request.  In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. 

Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. 

  Abuse and Neglect   Judicial and Administrative Proceedings 

  Law Enforcement Emergencies (Suicidal intent) 

  National Security Public Safety (Duty to Warn) 

  Drug use in Pregnancy 

Without Authorization:  Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations.  The types of uses and disclosures that may be made without your authorization are those that are: 

• Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department) 
• Required by Court Order 
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. 
• If a non-custodial parent requests information, they may receive information about our services for their child, but not about services to the other parent.,  
• If there is an emergency we may communicate your condition to a family member or other appropriate persons. 
• If your account is delinquent, we may attempt to obtain reimbursement through small claims court or to a collection agency. We may also report delinquent accounts to credit bureaus. 
• Examination of records for an audit or accreditation. 
• To meet federal, state, and local statistical requirements. 

VerbalPermission:   We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission. 

With Authorization:  Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. 

Regarding Minors: Minnesota State Law authorizes that a minor has the right to request the private data about them be kept from their parents in regards to the following: venereal diseases, pregnancy, associated conditions, and alcohol or other drug use.  

Providing Information About You: You are not required to provide information about yourself; however, without some information we may not be able to provide the most appropriate services. If you are here because of a court order, and you refuse to provide information, that refusal may be communicated to the court. 

YOUR RIGHTS REGARDING YOUR PHI 

You have the following rights regarding your personal PHI maintained by our office.  To exercise any of these rights, please submit your request in writing to our Privacy Officer, Patty Hill, MSW, LICSW, at 763-400-7075: 

• Right of Access to Inspect and Copy.  You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care.  Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you.  We may charge a reasonable, cost based fee for copies. 
• Right to Amend.  If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. 
• Right to an Accounting of Disclosures.  You have the right to request an accounting of certain of the disclosures that we make of your PHI.  We may charge you a reasonable fee if you request more than one accounting in any 12-month period. 
• Right to Request Restrictions.  You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations.  We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.   
• Right to Request Confidential Communication.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. 
• Breach Notification. If there is a breach of unsecured protected health information concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself 
• Right to a Copy of this Notice.  You have the right to a copy of this notice. 

COMPLAINTS 

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with Patty Hill, MSW, LICSW, our Privacy Officer, at 763-400-7075, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257.  We will not retaliate against you for filing a complaint.