Notice of Privacy Practices

Your Rights

Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To Inspect and Copy PHI

You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee. The Practice may deny your request if it believes the disclosure will endanger your life or another person’s life. You may have a right to have this decision reviewed.

To Amend PHI

You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request. The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To Request Confidential Communications

You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To Limit What Is Used or Shared

You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer. You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To Obtain a List of Those With Whom Your PHI Has Been Shared

You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To Receive a Copy of This Notice

You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To Choose Someone to Act for You

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To File a Complaint If You Feel Your Rights Are Violated

You can file a complaint by contacting the Practice:

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/.

The Practice will not retaliate against you for filing a complaint.

To Opt Out of Receiving Fundraising Communications

The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

Our Uses and Disclosures

1. Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you: The Practice can use and share PHI with other professionals who are treating you. For example, your primary care doctor may ask about your mental health treatment.

To run health care operations: The Practice can use and share PHI to run the business, improve your care, and contact you. For example, the Practice uses PHI to send you appointment reminders if you choose.

To bill for your services: The Practice can use and share PHI to bill and get payment from health plans or other entities. For example, the Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures That May Be Made Without Your Authorization

The Practice may use or disclose PHI without your authorization or an opportunity for you to object in several circumstances.

To help with public health and safety issues: This includes preventing the spread of disease, assisting in product recalls, reporting adverse reactions to medication, and preventing a serious and imminent threat to health or safety. It also includes reporting abuse, neglect, or domestic violence, and complying with requests from the Secretary of Health and Human Services for compliance investigations.

Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

To comply with law, law enforcement, or other government requests: This includes responses required by federal, state, or local law; judicial and administrative proceedings such as court orders, subpoenas, or discovery requests; law enforcement purposes to locate and identify individuals or disclose information about a victim of a crime; specialized government functions including military, national security, intelligence, protective services, and security clearance matters; and workers’ compensation compliance.

Other authorized disclosures: Coroners and funeral directors to perform legally authorized duties, organ donation and transplantation organizations, research that has been approved by an institutional review board, inmate care when PHI was created in the course of providing care, and business associates who perform functions, activities, or services on our behalf.

3. Uses and Disclosures With Your Authorization or Opportunity to Object

Unless you object, the Practice may disclose PHI to your family, friends, or others if the PHI directly relates to that person’s involvement in your care. The Practice may also disclose PHI if it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures Based Upon Your Written Authorization

The Practice must obtain your written authorization to use and/or disclose PHI for marketing, sale of PHI, and psychotherapy notes. You may revoke your authorization at any time by contacting the Practice in writing using the information above. The Practice will not use or share PHI other than as described in this Notice unless you give your permission in writing.

Our Responsibilities

The Practice is required by law to maintain the privacy and security of PHI. The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.

The Practice reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice using the information above, or by viewing a copy on the practice website at districtcounseling.com.

The Practice will inform you if PHI is compromised in a breach.

This Notice is effective as of November 19, 2021.