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Terms and Policy

NOTICE OF PRIVACY PRACTICES
Please review this notice carefully. If you have questions about this notice, please contact Jeri Marshall, LPC-S, at the number at the top of this form.

Beginning April 14, 2003, the law requires that you may be given a copy of the Notice of Privacy Practices, which describes how medical information about you may be used and disclosed and how you have access to it. We are required to abide by the terms of the notice of Privacy Practices hat is most current. We reserve the right to change the terms of the Notice at anytime. Any changes will be effective for all protected health information that we maintain. You may request a revised Notice at any time.

Your Rights Under the Privacy Rule

Following is a statement of your rights, under the Privacy rule, in reference to your protected health information. Please feel free to discuss any questions you may have.

You have the right to receive, and we are required to provide you with, a copy of this Notice.

We are required to follow the terms of this notice.

You have the right to authorize other use and disclosure-This means you have the right to authorize or deny any other use or disclosure of protected health information not specified in this notice. You may revoke an authorization, at any time, in writing. However, this will not effect any use or disclosure made by us prior to the revocation. In addition, if the authorization was obtained as a condition of attaining insurance coverage, the insurer may have the right to contest the policy of a claim under the policy even if you revoke the authorization.

You have the right to inspect and copy your protected health information-This means you may inspect and obtain a copy of protected health information about you that is contained in your patient record. In certain cases we may deny your request, particularly with regards to raw testing data.

You have the right to request a restriction of your protected health information-This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment of healthcare operations. In certain cases we may deny your request for restriction.

You may have the right to have us amend your protected health information-This means you may request an amendment of your protected health information. You must submit sufficient information to support your request, and your request must be made in writing.

You have the right to complain to us about our privacy practices- You have the right to complain to the Security of the Department of Health and Human Services about our privacy practices. You will not face retaliation from us fro making complaints.

You have the right to received confidential communications from us.

How We May Use or Disclose Protected Health Information:

Following are examples of use and disclosures of your protected health care information that we are permitted to make.

for treatment- We may use and disclose protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that is involved in your care and treatment.

for payment-Your protected health information will be used, as needed, to obtain payment for health care services.

for healthcare operations-We may use or disclose, as needed, your protected health information in order to support the business activities of my practice.

Other permitted and Required Uses and Disclosures

There are certain situations where we are allowed to disclose information from your record without your permission. In these situations, we must use our best professional judgment before disclosing information about you. Usually, we must determine that the disclosure is in your best interest, and may have to meet certain guidelines and limitations. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.

The Others Involved in Your Healthcare-With your written permission, we may disclose to a person you choose your protected health information that directly related to that person's involvement in your healthcare.

For Legal Proceedings-We may disclose information from you record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even if this is not ordered by the court.

For Health Oversight-We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits and investigations of possible health fraud. This is also included disclosing inappropriate conduct made by another health care provider, such as sexual contact made by another mental health provider.

In Cases of Abuse or Neglect - It is a state law that anyone who suspects abuse or neglect of a child or elderly person must report it to the appropriate regulatory agency within 48 hours.

In Case of Serious Threats to Safety - We may disclose information from your record if we believe it is necessary to prevent or lessen a serious and imminent threat to the safety of a person or the public.

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