THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Pledge Regarding Mental Health Information
The privacy of your mental health information is critically important to us. We understand that your health information is personal and we are committed to protecting it. We create a record of the care and the treatment you receive here. We maintain this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share health information about you. It also describes your rights and certain duties we have regarding the use and disclosure of protected mental health information.
Our Legal Duty:
Law Requires Us to:
- Keep your health information private
- Give you this notice describing our legal duties, privacy practices, and your rights regarding your health information.
- Follow the terms of the notice that is now in effect.
We Have the Right to:
- Change our privacy practices and the terms of this notice at any time, provided the changes are permitted by law.
- Make effective the changes in our privacy practices and new terms of our notice for all health information we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
- Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
Use and Disclosure of Your Protected Mental Health Information
The following section describes different ways that we use and disclose protected health information. Not every use and disclosure will be listed. However, we have listed all the different ways we are permitted to use and disclose health information. We will not use or disclose your mental health information for any purpose not listed below without your written authorization. Any specific written authorization you provide may be revoked at any time by submitting a written request to do so.
Treatment Purposes: We may use health information about you to provide you with health treatment or services. We may disclose health information about you to staff who are taking care of you. We may also share information about you with other health care providers to assist them in treating you.
Payment Purposes: We may use and disclose your health information for payment purposes. We may submit requests for payment to your insurance company. The insurance company maintains the right to request certain information from us regarding the care given. We will provide the required information to them about you and the care is given so that you may access your insurance benefits.
Operation Purposes: We may share your health information for our business-related matters, such as audits, billing services, accounting, and legal services. We also may use and disclose your health information for our health care operations. This may include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses, and credentials we need to service you.
Other Disclosures & Uses Required/Permitted by Law Include:
Abuse & Neglect: All practitioners of Hope Counseling and Consulting LLC are mandated by Alaska State Law to report suspected abuse and neglect of children, elderly, and persons with disabilities.
Court Proceedings:
We may disclose your protected information in the course of any judicial or administrative proceeding as allowed or required by law, with your specific written consent, or as directed by a judge’s court order. We do not routinely release protected information in response to an attorney’s subpoena.
Harm to Self or Others: To avert a life-threatening situation, we may disclose your protected information consistent with applicable law to prevent an imminent threat to the health or safety of a person or the public.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as reporting of certain types of sounds), pursuant to court orders, reporting limited information concerning identification and location at the request of law enforcement officials, reporting death, crimes on our premises, and crimes in emergencies.
Notification: In the event of an emergency, hospitalization, and with your permission, we may use or disclose your protected information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition. In case of emergency and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to professional judgment.
Workers Comp: If you are seeking compensation through Workers Compensation, we may disclose your protected information to the extent necessary to comply with laws relating to Workers Compensation.
Other Uses: Other uses and disclosures besides those identified in this notice will be made only as authorized by law or with your specific written consent, which you may revoke in writing at any time.
Your Information Rights
The health and billing records we maintain are the physical property of Hope Counseling and Consulting LLC. The information in it, however, belongs to you.
You have a right to:
- Request a restriction on certain uses and disclosures of your file by delivering the request in writing to our office. We are not required to grant the request, but we will carefully review any request received.
- Obtain a paper copy of this notice by making a request at our office.
- Request that you be allowed to inspect and/or receive a copy of your file and/or billing record. You may exercise this right by delivering your request in writing to our office. Payment of one dollar per page is due when file copies are picked up.
If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s file may not be accessible to you. This determination is made by the minor’s therapist if he/she determines that your access to the file would be harmful.
- Request that your file be amended to correct incomplete or incorrect information by delivering a written request to our office. We are not required by law to make such amendments.
- File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your file.
- Obtain an accounting of disclosures of your information as required by law by delivering a written notice to our office. An accounting will not include internal uses for treatment, payment, or disclosures made to you at your request.
- Revoke authorizations that you made previously except to the extent information or action has already been taken, by delivering a written revocation to our office.
- Review this notice before signing any consent authorizing use and disclosure of your protected information for treatment, payment, and operation purposes.
If you want to exercise any of the above rights, please contact the Privacy Officer, Dr. John DeRuyter, (907) 451-8208, 530 7th Avenue, Fairbanks, AK, 99709, by phone or in writing during normal business hours. He will provide you with assistance on the steps to take to exercise your rights.
Our Responsibility
Hope Counseling and Consulting LLC is required to:
- Maintain the privacy of your information as required by law;
- Provide you with a notice stating our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of this notice;
- Notify you if we cannot accommodate a requested restriction or request; and
- Accommodate your reasonable requests regarding methods to communicate information about you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected information we maintain. If our information practices change, we will amend our notice. You are entitled to receive a revised copy of this notice by calling and requesting a copy or by picking one up at our office.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to file a complaint regarding the handling of your information, you may contact the Privacy Officer, Dr. John DeRuyter, at (907) 451-8208, during normal business hours.
If you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Dr. DeRuyter. You also may file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Hope Counseling and Consulting LLC will not retaliate against you if you file a complaint. We cannot, and will not require you to waive the right to file a complaint with the Department of Health and Human Services as a condition of receiving treatment from our office.
THIS NOTICE WAS LAST REVISED 9-17-18
By my signature, I confirm that I have read and understood the above privacy policies. Any questions I had have been answered.