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.
Our Legal Duty
Psychology Associates of the Fox Cities (PA-FC) is committed to protecting the privacy of our clients confidential health information. We are required by law to:
|•||Maintain the privacy of your health information; and,|
|•||Provide you with this notice of our legal duties and privacy practices with respect to your personal health information.|
If you have any questions about any part of this notice or if you want more information about the privacy practices at PA-FC, please contact us using the information listed at the end of this notice.
Effect Date of This Notice
This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time. The terms of this notice apply to all designated PA-FC records containing your protected health information that are created and maintained by our clinic. Any changes to the Notice will be effective for all of your records created or maintained in the past as well as any records we create or maintain in the future. We will post a copy of the most current Notice in a prominent location within our facility and on our web site. PA-FC will abide by the terms of the notice currently in effect. At any time, you may request a copy of our most current Notice. You will be asked to acknowledge receipt of the Notice of Privacy Practices in writing.
Who will Follow Our Privacy Practices
PA-FC provides psychological care to our clients in partnership with physicians and other professionals and organizations. Our privacy practices will be followed by:
|•||Any health care professionals who care for you at PA-FC.|
|•||All locations that are staffed by our workforce.|
|•||All members of our clinic workforce including therapists, consultants, and staff members.|
Purposes for Which We Use and Disclosure Your Health Information
We are committed to ensuring that your health information is used responsibly by our organization. We may use and disclose your health information, without your written authorization, for the following purposes:
|1.||Treatment: We may use or disclose your health information for treatment purposes. While you are a client at our clinic, we may find it necessary to share your health information with other staff members involved in your care. We may also share your health information with other healthcare organizations that may participate in your care and treatment such as another clinician or hospital (for emergent care reasons).|
|2.||Payment: Your health information may be used or disclosed without your consent for payment purposes. It may be necessary for us to disclose your health information so that we may bill and collect from you, your insurance company or other party responsible for payment for the treatment and services provided.|
|3.||Health Care Operations: Your health information may be used for our organizational operations that are necessary to ensure that we provide the highest quality of care. For example, your health information may be used for performance improvement purposes.|
|4.||Information Provided to You: We may use your health information to assist us in communicating with your appointment reminders, test results, and treatment information. We may also use and disclose your health information to inform you of health related benefits or services that we or an affiliated entity provides that may be of interest to you. Our communications to you may be by phone or by mail.|
|5.||Notification and Communication With Family and Friends: We may share health information about you with family members or friends who are involved in your clinical care. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communicating with your family and others.|
|6.||Required by Law: We may use or disclose your health information only as allowed by law. Examples of situations where we may be required or permitted to release your health information include:|
|a.||to report child and /or adult abuse, neglect, or domestic violence;|
|b.||for health care oversight activities;|
|c.||for judicial and administrative proceedings;|
|d.||to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, identifying or locating a suspect, fugitive materials witness, or missing person;|
|e.||to coroners, medical examiners and funeral directors;|
|f.||to avert a serious threat to health or safety of the general public;|
|g.||for specialized government functions such as military and veterans activities, national security, and intelligence activities;|
|h.||to correctional institutions and law enforcement regarding inmates; and|
|i.||for worker’s compensation purposes.|
|7.||Research: In certain situations, we may use and share your health information for research purposes. However, all research projects are subject to special review and approval process designed, among other things, to ensure the privacy of your health information.|
|8.||Fund-raising: PA-FC does not engage in any fund raising activities. We do not sell or provide client information for any reason; therefore, you should not respond to any solicitation of “donations” on behalf of PA-FC.|
|9.||Disaster Relief: We may use or disclose your name and location to a public or private entity authorized by law or by its charter is assist in disaster relief efforts.|
Other Purposes For Which We Use and Disclosure Your Health Information
In any other situations not covered by this Notice as noted above, we will ask for your written authorization before using or disclosing information about you. If you choose to authorize disclosure of information about you, you can later revoke that authorization at any time by notifying us in writing of your decision.
Your Rights Regarding Your Health Information
As a client of PA-FC you have certain rights to regard to the health information that is maintained by our organization. These rights are as follows:
|1.||Access: With few exceptions, you have the right to access and receive a copy of your health information. The request must be made in writing. If you request a copy, it should be requested in advance and we may charge for the cost of copying, postage and/or other related supplies. In certain situations, we may deny your request. If we deny your request, we will tell you, in writing, why your request was denied and explain to you your right to have the denial reviewed.|
|2.||Disclosure Accounting: You have a right to receive a list or accounting of those disclosures, which PA-FC has made regarding your health information for purposes other than treatment, payment healthcare operations, information provided directly to you, and information disclosed as a result of mandated government functions. The request must be made in writing. Your request for the accounting must state a specific time period which may not be longer than six years and may not include dates before April 14, 2003. The first accounting in a 12 month period is free. Other requests may be charged according to our cost for producing the information.|
|3.||Amendment: You have the right to request that your health information be amended if you feel it is incorrect or incomplete. The request must be made in writing. PA-FC will review the request and make a determination as to whether or not an amendment will be made. If we did not create the information that you feel is incorrect or incomplete, we may deny your request. PA-FC will communicate to you in writing the final decision on your request, as well as provide information to appeal a denial of your request should it occur.|
|4.||Confidential Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. The request must be made in writing, and your request must represent that the information could endanger you if it is not communicated in confidence as you requested. We have the right to decide whether the request is reasonable. We do not have to comply with an unreasonable request.|
|5.||Restriction: You have the right to request restrictions on certain disclosures of your health information. The request must be made in writing. We will consider your request and determine our ability to carry out your request, while not compromising your care.|
|6.||Notice: You have the right to receive a paper copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time or you may print a copy from our web site at WWW.PA-FC.COM.|
Questions and Complaints
If you want more information about our privacy practices, or if you would like to exercise one or more of your rights regarding your health information, please contact us using the information listed at the end of this notice.
If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about your rights to your health information, you may complain to us using the information listed at the end of this notice. The complaint must be made in writing. You may also send a written compliant to the Secretary of the U.S. Department of Health and Human Services Office of Civil Rights. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
You may contact us using the information listed below:
Psychology Associates Fox Cities
1427-C Province Terrace
Menasha WI 54952
Email: [email protected]