Harmony Autism Therapy's
HIPAA AND PRIVACY PRACTICES
Acknowledgement and Reciept
Please read and then sign & date on following page
NOTICE OF PRIVACY PRACTICES
PROTECTED HEALTH INFORMATION (PHI)
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
THIS NOTICE DESCRIBES HOW MEDICAL AND PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. For the purposes of this document, “patient” refers to the individual receiving behavioral health services. “Parent/guardian” refers to the patient’s legal representative.
This notice describes our policies related to the use of the records of your child’s care at Harmony Autism Therapy. We are required to give you this Notice about (1) the use and disclosure of your health information, (2) our legal responsibilities, and (3) your rights concerning your health information and to abide by the terms of this notice. You may request a copy of our Notice of Privacy Practices at any time. For more information about our privacy practices, or for additional information, contact our Privacy Officer, Selma Martinez, 2104 Daybreak Dr., Lake in the Hills, IL 60156, (855) 690-2192 or fax (888) 972-2192.
Protected Health Information (PHI)
PHI is information about the patient relating to a past, present, or future mental health condition, or treatment or payment for the treatment that can be used to identify the patient. This includes any information, whether oral or recorded in any form that is created or received by Harmony Autism Therapy. This also includes electronic information and information in any other form or medium that could identify the patient. Examples of information that can identify a patient include, but are not limited to contact information, date of birth, social security number, service dates, diagnosis.
1. Our Duty is to Safeguard Your Protected Health Information.
Individually identifiable information about your past, present, or future health or condition, the delivery of health care to you, or the payment for the health care is considered "Protected Health Information" (PHI).
We are required to follow the privacy practices described in this Notice, although we reserve the right to change our privacy practices and the terms of this Notice at any time.
2. How We May Use and Disclose Your Protected Health Information.
Generally, we are permitted to use and/or disclose your PHI for your Treatment, the Payment for services you receive, and for our normal health care Operations (TPO) and special circumstances. For most other uses and/or disclosure of your PHI, you will be asked to grant your permission via a signed Authorization. However, we are permitted to make certain other uses and/or disclosures of your PHI without your authorization. Uses and/or disclosures are permitted as follows:
Uses and/or disclosures related to your treatment, our payment, or our health care operations (TPO) and special circumstances:
- For treatment (T): We may exchange your PHI with your doctor, psychologist, psychiatrist, dentist, or other healthcare provider to make sure you receive proper care. For example, we may use a patient’s protected health information to provide the patient with services, and may disclose this information to any and all Harmony Autism Therapy staff involved with the patient’s treatment. Treatment includes (a) activities performed by Harmony Autism Therapy personnel in the course of providing service to the patient or in coordinating or managing the patient’s service with other service providers and (b) consultations with and between Harmony Autism Therapy staff and other professionals involved in the patient’s treatment.
- For payment (P): We may exchange your PHI with Medicare, other health insurance plans, and business agents who may have to make sure the treatment you receive is paid for. For example, we may use and disclose the patient’s protected health information so we may bill and collect payment from the client, an insurance company, or another party for services Harmony Autism Therapy provided to the patient. We may also inform the patient’s health plan provider of treatment we intend to administer to obtain prior approval or to determine whether the patient’s plan will pay for the treatment.
- For health care operations (O): We may exchange your PHI with other Business Associates and health care review organizations to make policy decisions that could affect you and others enrolled in DHS Programs. Harmony Autism Therapy may use and disclose the patient’s protected health information in order to maintain necessary administrative, education, quality assurance, and business functions. For example, we may use a patient’s protected health information to evaluate the performance of our staff in providing treatment for the patient. We may also use information about patient evaluate what additional services to offer, how we can improve efficiency, or the effectiveness of certain treatments. Additionally, we may use protected health information for review, analysis, and other teaching and learning purposes. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.
- Special Circumstances
Services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals or organizations, or under other conditions and as mandated by state and federal law and our professional codes of conduct/ethics. These exceptions are discussed below.
· Professional Consultations
Behavior analysts may sometimes consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our patients/clients, and any consulting professionals are also required to refrain from disclosing any information we reveal to them. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Release of Information authorization that specifies what information can be released and with whom it can be shared. Your payer may require your signature on certain forms (i.e., continuity of care) in order to obtain coverage. We are not responsible for any charges due to patient non-compliance with their payer/payer’s requirements for coverage or payment.
· Professional Records
You should be aware that, pursuant to HIPAA, we keep clients’ Protected Health Information in one set of professional records. The Clinical Record includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. Personal notes are taken by staff; while the contents of personal notes vary from patient/client to patient/client, most are antidotal notes related to progress and future goals, reference to conversations, and hypotheses of the professional. These Personal Notes, including process notes are kept separate from the Clinical Record are not available to you and cannot be sent to anyone else, including the insurance company.
By signing this agreement you waive all rights, now and in the future, to accessing these records in any form under any circumstances. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.
· Treatment Information: We may use and disclose the patient’s protected health information to contact him/her about treatment information.
· Satisfaction Surveys: We may use and disclose the patient’s protected health information to contact the parent/guardian about Harmony Autism Therapy satisfaction surveys.
· Appointment Reminders: Unless you request that we contact you by other means, we are permitted to send appointment reminders and other similar materials to your address.
Uses and/or disclosures requiring your Authorization: Generally, most uses and/or
disclosures of your PHI for purposes other than TPO and special circumstances will require your signed Authorization. You retain the right to revoke your Authorization at any time except to the extent that we have already undertaken an action in reliance upon your Authorization.
INFORMATION DISCLOSED WITHOUT YOUR CONSENT Under state and federal law, information about you may be disclosed without your consent in the following circumstances.
o Child, elder or disabled individual abuse
o Public health activities
o Health oversight activities
o Lawsuits or disputes
o Judicial and administrative proceedings
o Law enforcement activities
o Research purposes
o Military and veterans
o Business associates
o Coroners, medical examiners and funeral directors about decedents
o Correctional facilities
o Prevent a serious threat to health or safety, disaster relief
o Specific government functions; national security; intelligence activities; protective services to the President and others
o Criminal activity or danger to others
o Research, and marketing and fundraising
· Emergencies. Sufficient information may be shared to address an immediate emergency you are facing.
· Judicial and Administrative Proceedings. We may disclose your personal health information in the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for Workers Compensation.
· Public Health Activities. If we felt you were an immediate danger to yourself or others, we may disclose health information about you to the authorities, as well as alert any other person who may be in danger.
· Child/Elder Abuse. We may disclose health information about you related to the suspicion of child and/or elder abuse or neglect.
· Criminal Activity or Danger to Others. We may disclose health information if a crime is committed on our premises or against our personnel, or if we believe there is someone who is in immediate danger.
· National Security, Intelligence Activities, and Protective Services to the President and Others. We may release health information about you to authorized federal officials as authorized by law in order to protect the President or other national or international figures, or in cases of national security.
· Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances.
· Business Associates. Harmony Autism Therapy may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, Harmony Autism Therapy contracts with a financial audit firm to review the finances of Harmony Autism Therapy on a yearly basis. In the process of the audit, they may come in contact with client billing records. All of our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
· Research. Under certain circumstances, Harmony Autism Therapy may use and disclose health information for research. Before we do so, the project will go through a special approval process that includes a consent form for clients to sign if they are included in the research study. Even without the special approval, however, Harmony Autism Therapy may permit researchers affiliated with Harmony Autism Therapy. to look at non- identifying information to help them plan research projects.
· Marketing. Harmony Autism Therapy may send you newsletters or information about services we provide in which we feel you might be interested. You may at any time request that your name be removed from our mailing list. We will not disclose any information to a third party for their use in telemarketing, direct mail marketing, or marketing through electronic mail. For Marketing/Sales. Uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require authorization.
· Fundraising Activities. Harmony Autism Therapy may use certain client demographic information—such as your name and address—to contact you about fundraising. Harmony Autism Therapy regularly seeks contributions from the general public to support our charitable and educational programs such as free care for children and families in low-income communities, a reduced-fee clinic, student scholarships, and research projects. If you do not wish to be contacted about fundraising, send a written request to the Privacy Officer, Selma Martinez, 2104 Daybreak Dr., Lake in the Hills, IL 60156, (855) 690-2192 or fax (888) 972-2192.
· Scheduling Appointments. Harmony Autism Therapy may use your phone number to call you and leave messages to schedule or remind you of appointments.
Uses and Disclosures Requiring You to Have an Opportunity to Object
o Unless the parent/guardian notifies us that he/she objects, we may include certain information about him/her in Harmony Autism Therapy’s Directory in order to respond to inquiries and disseminate information more efficiently. This directory is accessed only by Harmony Autism Therapy staff who may or may not be involved in the client’s treatment.
o Unless the parent/guardian notifies us that he/she objects, we may provide his/her child’s protected health information to individuals such as the client’s family members, caregivers, and friends, who are involved in the client’s treatment or who pay for the patient’s treatment. We may do this if the client informs us we have their consent to do so, or if the client knows we are sharing the patient’s protected health information with these individuals and the parent/guardian expresses no objection or makes no reasonably discernable attempt to prevent us from doing so. There may also be circumstances when we can assume, based on our professional judgment, the parent/guardian would not object to disclosure of his/her protected health information. Also, if the patient is not able to approve or object to disclosures, we may make disclosures to a particular individual (such as a patient’s family member or friend), we feel are in the patient’s best interests and that relate to that person’s involvement in the patient’s care.
Your Rights Regarding Your Protected Health Information (PHI)
The parent/guardian has certain rights regarding his/her child’s health information, which are listed below. In each of these cases, if the parent/guardian wants to exercise his/her rights, he/she must do so in writing by completing a form that can be obtain from Harmony Autism Therapy. In some cases, we may charge the parent/guardian for the costs of providing materials to the parent/guardian. The parent/guardian can get information about how to exercise his/her rights and about any costs that we may charge for materials by contacting us or reading the Fee Schedule.
o Right to request restrictions on PHI uses and/or disclosures. You have the right to restrict certain disclosures of Protected Health Information to a health plan when you pay out of pocket in full for the healthcare item or service. While you are in treatment, a written request for the restriction should be made with your therapist. To request a restriction after therapy is completed, you must make your written request to the Privacy Officer of Harmony Autism Therapy. Harmony Autism Therapy has the right to request a restriction or limitation on the health information we use or disclose about the client (a) for treatment, payment, or health care operations, or (b) to someone who is involved in the client’s care or the payment for it, such as a family member or friend. We are not required to agree to the parent/guardian’s request. Any time Harmony Autism Therapy agrees to a restriction, it must be in writing and signed by the Director or his/her designee.
o Right to request confidential communications. The parent/guardian has the right to request we communicate with him/her about health matters in a certain method or at a certain place. For example, the parent/guardian can ask that we only contact his/her at home or by mail. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
o Right to access and copy your PHI. With some exceptions, the parent/guardian has the right to inspect and get a copy of the patient’s protected health information that may be used to make decisions about the patient’s care. We may deny the parent/guardian’s request to inspect and/or copy information in certain limited circumstances, and, if we do this, the parent/guardian may ask that the denial decision be reviewed.
o Right to request amendment of your PHI. The parent/guardian has the right to amend his/her health information maintained by Harmony Autism Therapy, or used by us to make decisions about the patient. We will require that the parent/guardian provide a reason for the request, and we may deny the request for an amendment if the request is not properly submitted, or if it asks us to amend information that (a) we did not create (unless the source of the information is no longer available to make the amendment), (b) is not part of the health information we keep, (c) is of a type the client would not be permitted to inspect and copy, or (d) is already accurate and complete.
o Right to Notification. You have the right to or will receive notifications of breaches of his or her unsecured PHI.
o Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
o Right to an accounting of disclosures of your PHI. The parent/guardian has the right to request an accounting of disclosures. An accounting is a list of certain disclosures we made regarding the patient’s protected health information. The list does not include all disclosures. For example, it does not include disclosure to the parent/guardian, disclosure for treatment, payment, and health care operations purposes described above, or disclosure made with the parent/guardian’s authorization as described above.
o Right to Obtain a Paper Copy of this Notice. You have the right to receive a paper copy of this notice and any amended notice upon request. A paper copy can be obtained by contacting us at email@example.com, by mail request, or by fax request. You may also obtain a copy of this notice at our web site, www.harmony-autism.com.
Any other uses and disclosures not set out in the information above will be made only with your written authorization. You may revoke a written authorization for release of information at any time. The revocation must be in writing and will become effective when it has been received by the Privacy Officer of Harmony Autism Therapy listed below and will only be for disclosures not already completed.
We reserve the right to change our privacy practices provided such changes are permitted by applicable law. Before the effective date of a material change, however, we will change this Notice and make a new Notice available to you at the reception desks or lobbies at each Harmony Autism Therapy site and on our web site. Beginning April 14, 2003, we are required to abide by the terms of Notice.
How to Complain about our Privacy Practices
If you believe that we may have violated your individual privacy rights, you may submit your written complaint to our Privacy Compliance Officer at the address provide below. Your written complaint must name the entity that is the subject of your complaint and describe the acts and/or omissions you believe to be in violation of the Rule or of the provisions outlined in our Notice of Privacy Practices. If you prefer, you may file your complaint directly with the Secretary of the U.S. Department of Health and Human Services Secretary, by calling (877) 696- 6775. However, any complaint you file must be received by us via certified mail, or filed with the Secretary, within 180 days of when you knew, or should have known, the act or omission occurred. If the patient/legal guardian believes privacy rights have been violated, contact: Office of Civil Rights, Medical Privacy Complaint Division U.S. Department of Health and Human Services,
200 Independence Ave., S.W. HHH Building, Room 509H Washington, D.C. 20201, Phone: (866) OCR-PRIV (627-7748) TTY: (886) 788-4989 www.hhs.gov/ocr
We will take no retaliatory action against you if you make such complaints. If you wish to file any complaints, please forward your written correspondence to: Selma Martinez, Privacy Compliance Officer, 2104 Daybreak Dr, Lake in the Hills, IL 60156, Phone (855) 690-2192, Fax (888) 972-2192.
I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment from Harmony Autism Therapy for my child.
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