Notice of Privacy Practices
Notice of Privacy Practices
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
IT
CAREFULLY.
Key
Issues
Uses
and
Disclosures:
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.
Continuity
of
care
is
part
of
treatment
and
your
records
may
be
shared
with
other
providers
to
whom
you
are
referred.
We
may
use
or
disclose
identifiably
health
information
about
you
without
your
authorization
in
several
situations,
but
beyond
those
situations,
we
will
ask
for
your
written
authorization
before
using
or
disclosing
any
identifiable
health
information
about
you.
Your
rights:
In
most
cases,
you
have
the
right
to
look
at
or
get
a
copy
of
health
information
about
you.
I
f
you
request
copies,
we
will
charge
you
only
normal
photocopy
fees.
You
also
have
the
right
to
receive
a
list
of
certain
types
of
disclosures
of
your
information
that
we
have
made.
If
you
believe
that
information
in
your
record
is
incorrect,
you
have
the
right
to
request
that
we
correct
the
existing
information.
Our
legal
duty:
We
are
required
by
law
to
protect
the
privacy
of
your
information,
provide
this
notice
about
our
information
practice,
follow
the
information
practices
that
are
described
in
this
notice,
and
seek
your
acknowledgement
of
receipt
of
this
notice.
Before
we
make
a
significant
change
in
our
policies,
we
will
change
our
notice
and
post
the
new
notice
in
plain
sight.
You
can
also
request
a
copy
of
our
notice
at
any
time.
Complaints:
If
you
are
concerned
that
we
have
violated
your
privacy
rights,
or
you
disagree
with
a
decision
we
have
made
about
access
to
your
records,
you
may
contact
the
person
listed
below.
You
may
also
send
a
written
complaint
to
the
US
Dept.
of
Health
and
Human
Services.
The
person
listed
can
provide
you
with
appropriate
contact
information
upon
request.
If
you
have
any
questions
or
a
complaint,
please
contact:
Thembi
DePass
240-620-3028
wellspringtherapy@yahoo.com
1123
MD
Route
3,
Suite
252,
Gambrills,
MD
21054
www.wellspringtherapyservices.com
Further
Details:
The
following
are
examples
of
types
of
uses
and
disclosures
of
your
protected
health
information
(PHI)
that
the
provider
is
permitted
to
make.
These
examples
are
not
meant
to
be
exhaustive,
but
to
describe
the
types
of
uses
and
disclosures:
Treatment:
We
will
use
and
disclose
your
PHI
to
provide,
coordinate
or
manage
healthcare
and
any
related
service.
For
example,
your
PHI
may
be
provided
to
a
doctor
to
whom
you
have
been
referred
to
ensure
that
the
doctor
has
the
necessary
information
to
diagnose
and
treat
you.
Payment:
Your
PHI
will
be
used,
as
needed,
in
activities
related
to
obtaining
payment
for
your
services.
For
example,
obtaining
approval
for
a
therapy
services
may
require
that
your
relevant
PHI
be
disclosed
to
your
health
insurance
company
to
obtain
approval
for
services.
Operations:
We
may
use
or
disclose,
as
needed,
your
PHI
in
order
to
support
our
business
activities.
For
example,
when
we
review
employee
performance,
we
may
need
to
look
at
what
an
employee
has
documented
in
your
medical
record.
Business
Associates:
We
may
share
your
PHI
with
a
third
party
business
associate
that
performs
various
activities
such
as
billing
or
transcription
services.
Whenever
an
arrangement
between
us
and
business
associates
involves
the
use
or
disclosure
of
your
PHI,
we
will
have
a
written
contract
that
contains
terms
that
will
protect
the
privacy
of
your
PHI.
Marketing:
We
may
use
or
disclose
certain
health
information
in
the
course
of
providing
you
with
information
about
treatment
alternatives,
health-related
services
or
fundraising.
You
may
contact
us
to
request
that
these
materials
not
be
sent
to
you.
Written
Authorization
Other
uses
and
disclosures
of
your
PHI
will
be
made
only
with
your
written
authorization,
unless
otherwise
permitted
or
required
by
law
as
described
below.
You
may
revoke
your
authorization,
at
any
time,
in
writing.
Opportunity
to
Object
We
may
use
and
disclose
your
PHI
in
the
following
instances.
You
have
the
opportunity
to
object.
I
f
you
are
not
present
or
able
to
object,
then
your
provider
may,
using
professional
judgment,
determine
whether
the
disclosure
is
in
your
best
interest.
Emergencies:
In
an
emergency
treatment
situation,
we
will
provide
you
a
Notice
of
Privacy
Practices
as
soon
as
reasonably
practicable
after
the
delivery
of
treatment.
Communication
Barriers:
We
may
use
and
disclose
your
PHI
if
we
have
attempted
to
obtain
acknowledgement
from
you
of
our
Notice
of
Privacy
Practices
but
have
been
unable
to
do
so
due
to
substantial
communication
barriers
and
we
determine,
using
professional
judgment,
that
you
agree.
1123
MD
Route
3,
Suite
252,
Gambrills,
MD
21054
www.wellspringtherapyservices.com
Without Opportunity to Object We may use or disclose your PHI in the following situations without your authorization or opportunity to object: Public Health: For public health purposes to a public health authority or to a person who is at risk of contracting or spreading your disease. Health Oversight: to a health oversight agency for activities authorized by law such as audits, investigations or inspections. Abuse or Neglect: to an appropriate authority to report child abuse and/or neglect, if we believe that you have been a victim of abuse, neglect or domestic violence. Food and Drug Administration: as required by the Food and Drug Administration to track products. Legal Proceedings: in the course of legal proceedings. Law Enforcement: for law enforcement purposes, such as pertaining to victims of a crime or to prevent a crime. Coroners, Funeral Directors and Organ Donation: for the coroner, medical examiner, or funeral director to perform duties authorized by law and for organ donation purposes. Research: to researchers when their research has been approved by an Institutional Review Board or Privacy Board. Soldiers, Inmates and National Security: to military supervisors of Armed Forces personnel or to custodians of inmates, as necessary. Preserving national security may also necessitate disclosure of PHI. Workers Compensation: to comply with workers compensation laws. Compliance: to the Dept. of Health and Human Services to investigate our compliance. In general, we may use or disclose your PHI as required by law and limited to the relevant requirements of the law. Your rights You have the right to: Inspect and copy your protected health information. Request a restriction of your protected health information. You may ask us not to use or disclose certain parts of your PHI for treatment, payment or healthcare operations. You may also request that information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, but if we do agree, then we must act accordingly.
www.wellspringtherapyservices.com
Acknowledgement of receipt of Notice of Privacy Practices: Please sign and print your name and date this acknowledgement form. Then detach the form from the Notice along the line and return your signed acknowledgement to your therapist. Signature:__________________________________________________________ Printed Name:_______________________________________________________ Date:______________________________________________________________
Request to receive confidential communications from us by alternative means or as an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Ask us to amend your PHI. You may request an amendment of PHI about you. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and your medical record will note the disputed information. Receive an accounting of certain disclosures we may have made. This right applies to disclosures for purposes other than treatment, payment or healthcare operations. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations. Obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
www.wellspringtherapyservices.com