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APRIL 14, 2003
NOTICE OF PATIENT PRIVACY
We are committed to preserving the privacy of your personal
health information. We are required by law to protect the
privacy of your medical information and to provide you with
Notice describing:
How medical information about you may be used and disclosed
and how you can access this information.
We use health information about you for treatment, to obtain
payment for treatment, for administrative purposes, and to
evaluate the quality of care that you receive.
Under certain circumstances we may be required to use and
disclose your mental health information without your consent
or authorization. As our patient/client, you have rights
relating to inspecting and copying your medical information
that we maintain, amending or correcting that information,
obtaining an accounting of our disclosures of your medical
information, requesting that we communicate with you
confidentially, requesting that we restrict certain uses and
disclosures of your health information, and complaining if
you think your rights have been violated.
A detailed Notice of Privacy Practices is available to you
which fully explains your rights and our obligations under
the law. We may revise our Notice from time to time. The
effective date is in the upper right hand corner of this
page.
You have the right to receive a copy of our most current
Notice in effect. If you have not yet reserved a copy you
may request one and we will provide you with a copy.
If you have any questions, concerns or complaints about the
Notice or your mental health medical information, please
contact , the office manager of Harbor Community
Psychological Associates, S.C.
NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices describes how we may use
and disclose your protected mental health information to
carry out treatment, payment or health care operations and
for other purposes that are permitted or required by law. It
also describes your rights to access and control your
protected health information. Protected Health Information
is information about you, including demographic information,
that may identify you and that relates to your past, present
or future physical or mental health or condition and related
health care services.
We are required to abide by the terms of this Notice of
Privacy Practices. We may change the terms of our Notice at
any time.The new Notice will be effective for all protected
health information that we maintain at that time. Upon your
request, we will provide you with any revised Notice of
Privacy Practices .
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit a healthcare provider, a record of your
visit is made. Typically, this record contains your symtoms,
examination, test results, diagnoses, treatment, and a plan
for future care or treatment. This information, often
referred to as your health or medical record, serves as a:
*basis for planning your care and treatment
*means of communication among the many health professionals
who contribute to your care
*legal document describing the care you received
*means by which you or a third-party payor can verify that
services billed were actually provided
*a tool in educating health professionals
*source of data for medical research
*source of information for pubic health officials charged
with improving the health of the nation
*source of data for facility planning and marketing
*a tool with which we can assess and continually work to
improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health
information is used helps you to:
*ensure its accuracy
*better understand who, what, when, and why others may
access your health information
*make more informed decisions when authorizing the
disclosure to others
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of the
healthcare practitioner or facility that compiled it, the
information belongs to you. You have the right to:
*request a restriction on certain uses and disclosures of
your information
*obtain a paper copy of the notice of information practices
upon request
*inspect and obtain a copy of your health record
*amend your health record
*obtain an accounting of disclosures of your health
information
*request communication of your health information by
alternative means
*revoke your authorization to use or disclose health
information except to the extent that action has
already been taken
OUR RESPONSIBILITIES
This organization is required to:
*maintain the privacy of your health information
*provide you with information we collect and maintain about
you, as to our legal duties and privacy
practices
*abide by the terms of the Notice
*notify you if we are unable to agree to a requested
restriction
*accommodate reasonable requests you may have to communicate
health information by alternative
means or alternative locations
We will not use or disclose your health information without
your authorization, except as described in this notice.
If you believe your privacy rights have been violated, you
can file a complaint with our Privacy Contact or with the
Secretary of Health and Human Services. There will be no
retaliation for filing a complaint. You may contact our
Privacy Officer, Kathy Brunhoefer at (920) 964-2100 for
further information about the complaint process.
EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH
OPERATIONS
We will use your health information for treatment.
Example: Information obtained by a therapist or other member
of your healthcare team will be recorded in your record and
used to determine the course of treatment that should work
best for you. We may provide your physician or a subsequent
healthcare provider with copies of various reports that
should assist him or her in treating you.
We will use your health information for payment.
Example: A bill may be sent to you or a third-party payor.
The information on or accompanying the bill may include
information that identifies you as well as your diagnosis,
procedures, and supplies used.
We will use your health information for regular health
operations.
Example: Members of our quality improvement team may use
information in your health record to assess the care and
outcomes in your case and others like it. This information
will then be used in an effort to continually improve the
quality and effectiveness of the healthcare and service we
provide.
Business associates.
Example: There are some services provided by other business
associates such as collection agencies that need copies of
your demographics and health information for further
payment.
Notification: We may use or disclose information to notify
or assist in notifying a family member, personal
representative, or another person responsible for you care,
your location, and general condition.
Communication with family: Health professionals, using their
best judgment, may disclose to a family member, other
relative, close personal friend or any other person you
identify, health information relevant to that person’s
involvement in your care or payment related to your care
with a signed consent form.
Marketing: We may contact you to provide appointment
reminders or information about treatment alternatives or
other health related benefits and services that may be of
interest to you.
Workers Compensation: We may disclose health information to
the extent authorized by and to the extent necessary to
comply with the laws relating to workers compensation or
other similar programs established by law.
Public Health: As required by law, we may disclose your
health information to public health or legal authorities
charged with preventing or controlling disease, injury, or
disability.
Correction institution: Should you be in inmate of a
correctional institution, we may disclose to the institution
or agents thereof health information necessary for your
health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law
enforcement purposes as required by law or in response to a
valid court order.
Federal law makes provision for your health information to
be released to an appropriate health oversight agency,
public health authority or attorney, provided that work
force member or business associate believes in food faith
that we have engaged in unlawful conduct or have otherwise
violated professional or clinical standards and are
potentially endangering one or more patients, workers or the
public.
This Notice was published and becomes effective April 14,
2003.
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