Untethered Therapy Group, LLC
570 Lincoln Avenue • Bellevue, PA 15202 • 412 - 951 - 3857 (phone/fax)
HIPAA 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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, and healthcare operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
I. Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. The new notice will be available upon request, in our office, and on our website.
II. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your therapist, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the Untethered Therapy Group, LLC’s practice, and any other used required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a psychiatrist to whom you have been referred to ensure that the psychiatrist has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used as needed to obtain payment for your health care services. For example, obtaining authorization for treatment may require that your relevant protected health information be disclosed to the health plan.
Healthcare Operations: We may use or disclosed, as needed, your protected health information in order to support the business activities of Untethered Therapy Group, LLC’s practice. These activities include but are not limited to quality assessment, employee review, training of Interns, and licensing. For example, we may call you by a name in the waiting room when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointments.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law; Public Health issues, Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners, Funeral Directors, and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates. Under the law, we must also make disclosures to you, and when required by the Department of Health and Human Services to investigate or determine our compliance with the requirements of federal privacy laws.
Other Permitted and Required Uses and Disclosures will be made only with your written authorization or opportunity to object unless required by law. We never market or sell personal information.
You may revoke this authorization at any time, in writing, except to the extent that your therapist or Untethered Therapy Group, LLC’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
III. Your Rights
You have the right to inspect and receive a copy of your protected health information. Our practice will accept such requests in writing. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Under federal law, however, you may not inspect or receive a copy of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information.
You have the right to have your therapist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to obtain a paper copy of this notice from us. You have the right to request to receive confidential communications from us by an alternative means or at an alternative location (for example, home or office phone). We will agree to all reasonable requests.
You have the right to request a restriction on the disclosure of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. We are not required to agree to your request, and we may decline if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree unless a law requires us to share that information. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in you care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your therapist is not required to agree to a restriction that you may request. If a therapist believes it is in your best interest to permit use and disclosure of your protected health information, your health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
If you believe your privacy rights have been violated by us, you may file a written complaint with our office staff by submitting a letter briefly describing the nature of the violations you believe have occurred. You may also file a complaint with the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.
V. Effective Date: January 1, 2015
You hereby acknowledge receipt of our HIPAA Notice of Privacy Practices. All information shared will be held in confidence with certain limitations. Information will not be released without your written consent, except for professional consultation (if needed) and unless required by law. Your therapist is required by law to disclose information pertaining to suspected child or elder abuse or neglect; inability to care for one’s basic needs for food, clothing or shelter; and threatened harm to oneself or others. ·In select cases, the courts may subpoena counseling records. ·In addition, if you opt to bill your insurance company for counseling services, information regarding treatment and diagnosis will be provided to your insurance company. ·Furthermore, failure to pay for services in the agreed upon manner may result in information including client’s name, address, dates of service and outstanding balance being submitted for legal collection action. You may want to discuss further limits or exceptions of confidentiality.
Effective Date: January 1, 2015