Just Mind HIPPA Form
Just Mind HIPPA Form
Just Mind HIPPA Form
provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Abuse and Neglect Emergencies National Security Judicial and Administrative Proceedings Law Enforcement Public Safety (Duty to Warn)
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are: Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as state licensing boards or health department) Required by Court Order Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission. With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. YOUR RIGHTS REGARDING YOUR PHI You have the following rights regarding your personal PHI maintained by our office. To exercise any of these rights, please submit your request in writing to our Privacy Officer,_________Jan Dimmit_______________, at ___512-843-7665________________________: Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Right to a Copy of this Notice. You have the right to a copy of this Notice. Electronic Transactions Standards.
COMPLAINTS If you believe we have violated your privacy rights, you have the right to file a complaint in writing with ____Jan Dimmit_______________, our Privacy Officer, at _512-8437665_______________, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257. We will not retaliate against you for filing a complaint. The effective date of this Notice is __1/1/2010________________.