Notice of Privacy Practices

Introduction

We create a record of the health services you receive to further your care and to comply with
certain legal requirements. We are committed to your privacy and are required by law to
maintain the privacy and security of your protected health information. As part of our
commitment and legal compliance, we share this Notice of Privacy Practices (“Notice”).

Contact

If you have any questions about this Notice, please contact Rachel Harlich at 929-484-2440.

Scope

This Notice applies to all the information we generate, including information about past, present,
or future mental or physical health conditions. We follow - and our employees and other
workforce members follow - the duties and privacy practices that this Notice describes and any
changes once they take effect.

Changes to this Notice

We can change the terms of this Notice, and the changes will apply to all information we have
about you. The new notice will be available on request and on our website.

Data Breach Notification

We will promptly notify you if a data breach occurs that may compromise the privacy or security
of your health information.

Use and Disclosure of Your Information

There are situations where your health information may be used and disclosed by us. We have
listed some examples of permitted uses and disclosures below.

 

• Care and Treatment.

  • We may use or disclose your health information with health professionals who are treating you to help and will be given access to your health information.

  • If we are away or unavailable, another mental health professional might be on call

  • We may consult with other mental health professionals about your case, but wewill not give them personally identifiable information without your consent.

• Public Health and Safety Activities. We may communicate with family members,
  friends, law enforcement, and others if we feel there is a serious threat to your health and
  safety, or the health and safety of the public or another person. For example, we may
  share your information to:

  • ​prevent injury to you or others, and

  • report suspected child neglect or abuse, domestic violence, and elder abuse.

• Legal Proceedings and Law Enforcement.

  • ​We may be required by law to provide information about your health and our
    treatment in a legal proceeding; for instance, in a child custody case or if your
    psychological condition is an issue in a court case.

  • If required by law, we will share information about you for law enforcement
    purposes.

  • If required, we will share your information with a federal or state agency with
    oversight over our activities.

• For Payments and Services. We may use and share your health information to obtain
  prior approval for services or to receive payment from health plans or other entities.

• Our Business Associates. We may use and disclose your information to outside persons
  or entities that perform services on our behalf, such as auditing, legal, or transcription.
  We require these parties to use and disclose your information only as permitted and to
  appropriately safeguard your information.

​

When feasible, we will try to discuss the situation with you, or notify you, before any
confidential information is used or disclosed, and will only use or disclose the minimum amount
of information that is necessary.

Note: Disclosure of psychotherapy notes, HIV information, and alcohol and substance abuse
information requires specific authorization from you, unless such disclosure is required by law.
The recipient is prohibited from re-disclosing HIV-related information and information about
alcohol and substance abuse, unless specifically permitted to do so under federal or state law.

​

When We Will Not Use or Disclose Your Information

We will not share your information to:

• market our services, or

• sell or otherwise receive compensation for disclosing your information.

​

Your Rights and Choices

When it comes to your health information, you have rights. This section covers some of your
rights and some of our responsibilities to help you.

You have the right to:

• Inspect and Obtain a Copy of Your Information. You have the right to see or obtain
  an electronic or paper copy of the information we maintain about you, with some
  exceptions. For instance, we may not provide our personal notes and observations, and
  we may not provide information that could cause substantial harm to you or others. You
  may request your records and, if we deny all or part of your request, we will provide you
  with an explanation.

• Make Amendments. You may ask us to correct or amend information that we maintain
  about you that you think is incorrect or inaccurate. If we do not make the adjustment, we
  will make note of your request in your record.

• Authorize Disclosures of Your Information. You have both the right and choice to tell
  us whether to share information, such as your health information, general condition, or
  location, with your family, close friends, or others involved in your care. You can revoke
  these authorizations at any time and we will accommodate your requests as best we can,
  and as required by law.

• Request Restrictions on Our Disclosures in Emergency Situations. You have both the
  right and choice to tell us whether to share information in an emergency situation, such as
  to an organization or law enforcement, to assist with locating or notifying your family,
  close friends, or others involved in your care. We will make reasonable efforts to follow
  your instructions, but we may share your information if we believe it is in your best
  interest, according to our best judgment, and if you are unable to tell us your preference
  (for example, if you are unconscious) or when needed to lessen a serious and imminent
  threat to health or safety.

• Request Additional Restrictions. You have the right to ask us not to use or share certain
  information for treatment, payment, or operations or with certain persons involved in
  your care. For these requests, we may not agree to do it if we think it would impact your
  care, but we will discuss it with you.

• Request an Accounting of Disclosures. You have the right to request an accounting of
  certain disclosures that we have made. When responding to these requests, we will
  include all the disclosures except for those about treatment, payment, health care
  operations, and certain other disclosures, such as disclosures you asked us to make.

• Choose Someone to Act for You. If you have given someone medical power of attorney,
  or if you have a legal guardian, that person can exercise your rights and make choices
  about your information.

• Request Confidential Communications. You have the right to request that we
  communicate with you about health matters in a certain way or at a certain location. For
  example, you can ask that we only contact you at a specific address. For these requests,
  you must specify how or where you wish to be contacted, and we will accommodate
  reasonable requests.

• Make Complaints. You have the right to complain if you feel we have violated your
  rights. We will not retaliate against you for filing a complaint. You may either file a
  complaint:

  • directly with us by contacting Rachel Harlich, LCSW at 929-484-2440, or

  • with the Office for Civil Rights at the US Department of Health and Human
    Services, 886-627-7748, www.hhs.gov/ocr/privacy/hipaa/complaints/