Effective date

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how I may use or disclose your child's protected health information, with whom that information may be shared, and the safeguards I have in place to protect it. This notice also describes your rights to access and/or refuse the release of specific information outside of this system except when the release is required or authorized by law or regulation.

Acknowledgment of Receipt of this Notice

You will be asked to provide a signed acknowledgment of receipt of this notice. The intent is to make you aware of the possible uses and disclosures of your child's protected health information and your privacy rights. The delivery of your child's health care services will in no way be conditioned upon your signed acknowledgment.

Who Will Follow This Notice

This notice applies to all therapy services provided by Fundamental Therapy Inc. It also applies to office personnel and billing personnel.

Our Responsibility Regarding Protected Health Information

Your child's 'protected health information' is individually identifiable health information This includes demographics such as age, address, email address, and relates to your child's past, present, or future physical or mental health or condition and related health care services. We are required by law to do the following:

• Make sure that your child's protected health information is kept private
• Give you this notice of our legal duties and privacy practices related to the use of disclosures of your child's protected health information.
• Follow the terms of the notice currently in effect.
• Communicate any changes in the notice to you.

We reserve the right to change this notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised or changed notice effective for health information we already have about your child as well as any information received in the future. You may obtain a Notice of Privacy Practices by calling the phone number at the top of this notice.

Our System

Fundamental Therapy Inc works with several agencies and referral sources. Your child's health information will be shared in the following manner:

1. Treatment - I will use and disclose your child's protected health information to provide, coordinate, or manage your child's health care and any related services. This includes disclosure to your physician or other health care providers who become involved in your child's care.
2. Within my office for administrative activities, quality assessment, oversight, and peer review.
3. With my billing personnel and as necessary to obtain payment for your health care services.
4. With your insurance company or other payers as required for payment.
5. With the referring agency and case manager, if applicable.
6. With any other provider, school, or agency with your written request. You may request written or verbal information
   sharing in writing. Your request should include a specified period of time for information sharing.

Required by Law

I may use or disclose your child's protected health information if law or regulation requires the use or disclosure. I will notify the appropriate government authority if I believe a patient has been the victim of abuse, neglect, or domestic violence.

Health Oversight

I may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

Legal Proceedings

I may disclose protected health information during any judicial or administrative proceeding, in response to a court order or administrative tribunal (if such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful processes.

Parental Access

I may disclose your child's protected information to parents, guardians, and persons acting in similar legal status.

Uses and Disclosure of Protected Health Information Requiring Your Permission

In some circumstances, you have the opportunity to agree or object to the use or disclosure of all or part of your child's protected health information. Since this service is provided in your home or other natural environments, those present during the session, including friends, family, or daycare providers may hear health information regarding your child. Please notify your therapist if you do not want your child's protected health information to be discussed.

Your Rights Regarding Your Child's Health Information

You may exercise the following rights by submitting a written request to the Fundamental Therapy Inc office.

1. You may inspect and obtain a copy of your child's protected health information that is kept as a part of medical and billing records.
2. You may ask me not to use or disclose any part of your child's health information for treatment, payment, or health care operations. Your request must be made in writing. This request will be honored if we mutually agree that the restriction will not harm your child.
3. You may request that I communicate with you using alternative means or at an alternative location. I will not ask you the reason for your request. I will accommodate reasonable requests, when possible.
4. If you believe that the information I have about your child is incorrect or incomplete, you may request an amendment to your child's protected health information as long as I am responsible for maintaining this information. While I will accept a request for an amendment, I am not required to agree to the amendment.
5. You may request that I provide you with an accounting of the disclosures I have made of your child's protected health information. This right applies to disclosures made for purposes other than treatment, payment, or health care operations as described in the Notice of Privacy Practices. This disclosure must have been made after April 21, 2010, and no more than six years from the date of request. This right excludes disclosures made to you or authorized by you, to family members or friends involved in your child's care, or for notification. The right to receive this information is subject to additional exceptions, restrictions, and limitations as described earlier in this notice.

Federal Privacy Laws

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPPA). There are several other privacy laws that also apply including the Freedom of Information Act and the Privacy Act. These laws have been taken into consideration in developing policies and this notice of how I will use and disclose your child's protected information.

Complaints

If you believe these privacy rights have been violated, you may file a written complaint with the Department of Health and Human Services. No retaliation will occur against you for filing a complaint.