HIPAA 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.
General Information: This notice is effective as of February 1, 2017. The purpose of this notice is to inform you of the privacy practices of Two Chairs Behavioral Health Group, a Psychology Corporation (the “Provider”). The Provider is a Covered Entity as defined and regulated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We are required by law to protect the privacy of your protected health information (PHI). This Notice describes how we may use and disclose your PHI and your rights to access, change and manage your information according to both federal and state laws.
If you have any questions about this notice, would like a copy of this notice, need more information, or would like to request your records please contact: email@example.com.
1. WHAT IS PROTECTED HEALTH INFORMATION? (PHI)
PHI is information that individually identifies you that we get from you or from another health care provider, health plan, your employer, or a health care clearinghouse that relates to:
- Your past, present or future physical or mental health or conditions;
- The provision of health care to you; or
- The past, present, or future payment for your health care.
2. YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your health and claims records-
- You can ask to see or get a copy of your health and claims records and other health information we have about you.
- We will provide a copy or a summary of your health and claims records, within fifteen (15) days of your request.
- You can only direct us in writing to submit your PHI to a third party not covered in this notice.
- If your PHI is maintained in an electronic format you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. If the PHI is not readily producible in the form or format you request your record will be provided in a readable hard copy form.
- Special note regard psychotherapy notes: You do not have this right of access with respect to psychotherapy notes. The term “psychotherapy notes” means notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private assessment or counseling session or a group, joint, or family assessment or counseling session and that are separated from the rest of your medical (includes mental health) record. The term excludes medication prescription and monitoring, assessment or counseling session start and stop times, referrals that were proposed, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date, whether from us or from another practitioner with whom you met.
Ask us to correct health and claims records-
- You can ask us to correct your health and claims records if you think they are incorrect or incomplete.
- A request for an amendment must be made in writing to Two Chairs at the address provided at the beginning of this notice and it must provide the reason for your request.
- We may say “no” to your request, but we will tell you why in writing within sixty (60) days.
Request confidential communications-
- You can ask us to contact you in a specific way (for example, home or office or cell phone), a specific email address, or to send mail to a different address, such as a post office box.
- We will say yes to all reasonable requests, and must say “yes” if you tell us you would be in danger if we did not.
- You must make any request in writing and you must specify how or where we are to contact you.
Ask us to limit what we use or share-
- You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
- To request restrictions, you must make your request in writing to Two Chairs. Your request must state the specific restriction requested, whether you want to limit our use and/or disclosure; and to whom you want the restriction to apply.
- Please note: You understand that you have approved us to share information regarding you with any practitioner who we may propose as a referral for you, and we may receive reports from those practitioners or any practitioner regarding your past or future assessments or therapy.
Get a list of those with whom we’ve shared information-
- You can ask for a list (an accounting) of the times we’ve shared your health information within the last six (6) years prior to the date you ask, who we’ve shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
- To request this list or accounting of disclosures, you must submit your request in writing to Two Chairs.
Get a copy of this privacy notice-
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
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 and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated-
- You can complain if you feel we have violated your rights by contacting our Privacy/Security Officer at the address at the beginning of this Notice.
- 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/.
- We will not retaliate against you for filing a complaint.
3. YOUR CHOICES
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends or others involved in payment for your care.
- Share information in a disaster relief situation to coordinate your care or notify family and friends of your location.
- Include your information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
- Marketing purposes.
- Sale of your information.
4. OUR USES AND DISCLOSURES
How do we typically use or share your health information? We typically use or share your health information in the following ways:
a. Help manage the health care treatment you receive -
- We can use your PHI and share it with professionals who may be providing services to you, whether or not they were referrals we proposed to you. We can also ask clinicians that we refer you to about whether it was a good clinician-client match.
- Example: A therapist or primary care physician sends us information about your diagnosis and treatment plan or asks us about our assessment or treatment suggestions or recommendations.
b. Health Care Operations -
- We can use and disclose your information to run our practice, improve your care and contact you when necessary.
- Example: We use health information about you to provide you names of practitioners who may be well-suited to provide you with services that we would recommend.
c. Appointment reminders and treatment options -
- We may use and disclose PHI to contact you to remind you that you have an appointment, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
- Example: We use health information about you to provide you names of practitioners who may be able to provide services we do not provide or who may be more convenient or may have expertise or specialties that may be well-suited for you and to contact them regarding their availability to see you.
d. Payment for your health services -
- We can use and disclose your health information to bill and obtain payment from health plans or other entities for your health care services. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility, or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities.
- Example: We give information about you to your health insurance plan so it will pay for your services.
e. Business associates -
- We may use and disclose your PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services.
- Example: We use another company to do our billing or to provide transcription or consulting services for us and give them your PHI in order for them to complete this service. Pacific Psychotherapy Technologies, Inc., helps us with many aspects of our operations.
How else can we use or share your health information? We are allowed or required to share your information in other ways-usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index/html.
f. Help with public health and safety issues -
- We can share health information about you for certain situations such as:
- Preventing disease, injury or disability;
- Reporting adverse reactions to medications;
- Reporting suspected abuse, neglect, or domestic violence; and
- Preventing or reducing a serious threat to your health and safety or to the health or safety of others.
We will only disclose the information to someone who may be able to help with these situations.
g. Do Research -
- We can use or share your information for health research. We will only do this if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your PHI.
h. Comply with the law -
- We will share information about you if local, state, federal or international laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
i. Work with a medical examiner or funeral doctor -
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
- Address workers’ compensation, law enforcement, and other government requests-
j. Address workers’ compensation, law enforcement, and other government requests -
- We can use or share health information about you:
- For worker’s compensation claims;
- For law enforcement purposes or with a law enforcement official;
- With health oversight agencies for activities authorized by law, including audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws; and
- For special government functions such as military, national security, and presidential protective services.
k. Respond to lawsuits and legal actions -
- We can share health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested.
l. Conduct outreach, enrollment, care coordination and case management -
- We can share your information with other government benefits programs like Covered California and with private benefit programs, such as HMOs or managed care organizations, for reasons such as outreach, enrollment, care coordination, and case management.
m. Administer our programs -
- We can share your information with our contractors and agents who help us administer our programs.
n. Comply with special laws -
- There are special laws that protect some types of health information such as mental health services, treatment for substance use disorders, and HIV/AIDS testing and treatment. We will obey these laws when they are stricter than this notice.
We will never market or sell your personal information.
5. OUR RESPONSIBILITIES
- We are required by law to maintain the privacy and security of your PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of this information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice - We can change the terms of this Notice, and the changes will apply to all the PHI we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
This Notice of Privacy Practices applies to the following organization(s):
- Two Chairs Behavioral Health Group, a Psychology Corporation
- Pacific Psychotherapy Technologies, Inc.
For More Information- Please contact us to request a copy of this Notice in other languages or to get a copy in another format, such as large print or Braille.