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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO ME.

I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this notice about my privacy practices, my legal duties, and your rights concerning your health information. I must follow the privacy practices that are described in this notice while it is in effect.

This notice takes effect 01/01/2021, and will remain in effect until further notification.

MY LEGAL DUTY

I reserve the right to change my privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. I reserve the right to make the changes in my privacy practices and the new terms of my notice effective for all health information that I maintain, including health information I created or received before I made applicable changes. Before I make a significant change in my privacy practices, I will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about my privacy practices, or for additional copies of this notice, please contact me.

USES AND DISCLOSURES OF HEALTH INFORMATION

I use and disclose health information about you for treatment, payment, and healthcare operations for the following reasons:

• Treatment: I may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
• Payment: I may use and disclose your health information to obtain payment for services we provide to you.
• Healthcare Operations: I may use and disclose your health information in connection with my healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
• Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give me written authorization to use your health information or to disclose it to anyone for any purpose. If you give me an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give me a written authorization, I cannot use or disclose your health information for any reason except those described in this notice.
• To Your Family and Friends: I must disclose your health information to you, as described in the Patient Rights section of this notice. I may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
• Persons Involved in Care: I may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, I will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose health information based on a determination using my professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. I will also use my professional judgment and my experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
• Marketing Health-Related Services: I will not use your health information for marketing communications without your written authorization.
• Required by Law: I may use or disclose your health information when I am required to do so by federal or state law.
• Abuse or Neglect: I may disclose your health information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. I may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
• National Security: I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. I may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
• Appointment Reminders: I may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so.

You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. I will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending me a letter to the address at the end of this Notice. If you request copies, I will charge you $0.35 for each page, $15.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, I will charge a cost-based fee for providing your health information in that format. If you prefer, I will prepare a summary or an explanation of your health information for a fee. Contact me using the information listed at the end of this notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which I have disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 1, 2013. If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that I place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency

Alternative Communication: You have the right to request that I communicate with you about your health information by alternative means or to alternative locations (you must make your request in writing Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that I amend your health information (your request must be in writing, and it must explain why the information should be amended I may deny your request under certain circumstances.

Amendment: You have the right to communicate electronically (email, skype, SMS messaging, etc in a pre-approved manner with your provider. I will take all reasonable safeguards in maintaining methods to prevent unintentional disclosures of your personal health information; however this does not include personal information that has been pre-approved to be shared by continued use of the application itself through the individual mediums terms of use.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or any questions or concerns, please contact Elliott Kronenfeld, Ph.D., LICSW, CSTS.

If you are concerned that I may have violated your privacy rights, or you disagree with a decision I made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have me communicate with you by alternative means or at alternative locations, you may complain to me using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services.

I will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. I support your right to the privacy of your health information. I will not retaliate. File a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:

Elliott Kronenfeld, Ph.D., LICSW, CSTS
(617) 834-4235

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Dr. Elliott Kronenfeld, LLC's "Notice of Privacy Practices".

I understand that if I have any questions regarding the Notice or my privacy rights, I can contact my clinician.