Notice of Privacy Practices New Hope Counseling, Inc. Jim Valeri, LMHC 5 Edgell Rd. Framingham, MA 01701 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. I. Introduction This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights. This Notice further states the obligations we have to protect your health information. “Protected health information” means health information (including identifying information about you) we have collected from you or received from your health care providers, health plans, your employer or a health care clearing house. It may include information about your past, present or future physical or mental health or condition, the provision of your healthcare, and payment for your health care services. I am required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. We are also required to comply with the terms of our current Notice of Privacy Practices. II. How I Will Use and Disclose Your Health Information I will use and disclose your health information as described in each category listed below. For each category, we will explain what we mean in general, but not describe all specific uses or disclosures of health information. A. Uses and Disclosures That May Be Made For Treatment, Payment and Operations 1. For Treatment. I will use and disclose your health information for purposes of billing through your insurance company, provided insurance is used. 2. For Health Care Operations. I may use and disclose your privacy information without your authorization in order to run health care operations, such as supervision, licensure, quality assessment and improvement, business planning and development, and general administrative activities. B. Uses and Disclosures That May be Made without Your Authorization, But For Which You Will Have An Opportunity To Object 1. Persons involved in your care. We may provide health information about you to someone who helps pay for your care. We may use or disclose your health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may also disclose or use you r health information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures for this purpose to family or individuals involved in your health care. In limited circumstances, we may disclose health information about you to a friend or family member who is involved in your care. If you are physically present and have the capacity to make health care decisions, your health information may only be disclosed with your agreement to persons you designate to be involved in your care. But, if you are in an emergency situation, we may disclose your health information to a spouse, family member or a friend so that such person may assist in your care. In this case we will determine whether the disclosure is in your best interest and, if so, only disclose information that is directly relevant to participation in your care. And, if you are not in an emergency situation but are unable to make health care decisions, we will disclose your health care information to: - Your health care agent if we have received a valid health care proxy from you, - Your guardian or medication monitor if one has been appointed by a court, or, - If applicable, the state agency responsible for consenting to your care. C. Uses and Disclosures That May be Made Without Your Authorization or Opportunity to Object 1. Emergencies. I may use and disclose your health information without your authorization in an emergency treatment situation. By way of example, we may provide your health information to a paramedic who is transporting you in an ambulance. If a clinician is required by law to treat you and your treating clinician has attempted to obtain your authorization but is unable to do so, the treating clinician may nevertheless use or disclose your health information to treat you. 2. Research. I may disclose your health information to researchers when their research has been approved by an internal review board which has reviewed the research proposal and established protocols to protect the privacy of your health information. No personally identifying information about you will be disclosed to any external entity without your written authorization. 3. As Required By Law. I will disclose health information about you when required to do so by federal, state and local law. 4. To Avert Serious Threat to Health or Safety. I may use and disclose health information about you when necessary to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person. Under these circumstances, we will only disclose health information to someone who is able to help prevent or lessen the threat. 5. Public Health Activities. I may disclose health information about you as necessary for public health activities including, by way of example, disclosures to report, notify or conduct: - to public health authorities to prevent or control a disease, injury or disability - vital events such as birth or death - or conduct public health surveillance or investigations - child abuse/neglect - certain events to the FDA (Food & Drug Administration) regarding possible defective products or medication problems. - to consumers about FDA product recalls - notify a person who may have contracted a communicable disease or who may be at risk for spreading/contracting that disease - notify the appropriate government agency in the event that a child or adult has been the victim of abuse, neglect or domestic violence. I will only contact an agency with your consent, or if required to do so by law. 6. Disclosures in Legal Proceedings. I may disclose health information about you to a court when a judge orders me to do so. I may also disclose information about you in legal proceedings without your permission or a judge’s order when: - you are a party to a legal proceeding and I receive a subpoena for your health information. Normally, I will not provide this information in response to a subpoena without your authorization if the request is for substance abuse records or for information relating to AIDS or HIV status or genetic testing; - your health information involves communications made during a court-ordered psychiatric examination; - you introduce your mental or emotional condition in evidence in support of your claim or defense in any proceeding and the judge approves our disclosure of you health information; - you sue any of our clinicians or staff for malpractice or initiate a complaint with a licensing board against this clinician. - the legal proceeding involves child custody, adoption, or dispensing with consent to adoption and the judge approves of my disclosure of your health information; - I bring a proceeding, or I am asked to testify in a proceeding, involving foster care of a child or commitment of a child to the custody of the Massachusetts Department of Social Services. 7. Law Enforcement Activities. I may disclose health information to a law enforcement official for law enforcement purposes when: - you agree to the disclosure; or - when the information is provided in response to an order of a court; or - I determine that law enforcement purpose is to respond to a threat of an imminently dangerous activity against yourself or another person; or - the disclosure is otherwise required by law. I may also disclose health information about a client who is a victim of a crime, without a court order or without being required to do so by law. However, I will do so only if the disclosure or, in the case of the victim’s incapacity, the following occurs: - the law enforcement official represents to me that (i) the victim is not the subject of the investigation and (ii) an immediate law enforcement activity to meet a serious danger to the victim or others depends upon the disclosure; and - I determine that the disclosure is in the victim’s best interest. 8. Medical Examiners and Funeral Directors. I may disclose health information about my clients to a medical examiner. Medical examiners are appointed by law to assist in identifying the deceased persons and to determine the cause of death in certain circumstances. I may also disclose health information about my consumers to funeral directors as necessary to carry out their duties. 9. Military and Veterans. If you are a member of the armed forces, I may disclose your health information as required by military command authorities. I may also disclose your health information for the purpose of determining your eligibility for benefits provided by the Department of Veteran’s Affairs. Lastly, if you are a member of a foreign military service, we may disclose your health information to that foreign military authority. 10. National Security and Protective Services for the President and Others. I may disclose health information about you to authorized federal officials or intelligence, counter-intelligence, and other national security activities authorized by law. We may also disclose health information about you to authorized federal officials so they may conduct special investigations. 11. Inmates, Parole and Probation. If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may disclose health information about you to the local correctional institution or law enforcement official. II. Uses and Disclosures of Your Health Information with Your Permission. Uses and disclosures not described in Section II of this Notice of Privacy Practices will generally only be made with your written permission, called an “authorization.” You have the right to revoke an authorization at any time. If you revoke your authorization I will not make any further uses or disclosures of your health information under that authorization, unless I have already taken an action relying upon these uses or disclosures you have previously authorized. III. Your Rights Regarding Your Health Information A. Your Right to Inspect and Copy. You have the right to request an opportunity to inspect or copy health information used to make decisions about your care – whether they are decisions about your treatment or payment of your care. Usually, this would include clinical and billing records, but not psychotherapy notes. You must submit your request in writing to my attention at 5 Edgell Rd., Framingham, MA 01701. I may deny your request to inspect or copy your health information in certain limited circumstances. An appointment may be made to discuss the purpose and use of such information. B. Right To Amend. For as long as I keep records about you, you have the right to request that I amend any health information used to make decisions about your care - whether they are decisions about your treatment or payment of your care. Usually, this would include clinical and billing records, but not psychotherapy notes. You may send a request by mail to the above address, and I may deny your request if not in writing or does not supply a reason to support the request. I can also deny the request if: - the information was not created by myself, unless the person that made the information is no longer available; - is not part of the health information we maintain to make decisions about your care; - is not part of the health information that you would be permitted to inspect or copy; or - is accurate and complete. An appointment may be made to discuss the purpose and use of such a request. C. Right to an Accounting of Disclosures. You have the right to request that I provide you with an accounting of disclosures we have made of your health information. An accounting is a list of disclosures. But this list will not include certain disclosures of your health information for purposes of treatment, payment, and health care operations. A request of an accounting of disclosures should be sent in writing to the therapist at the address listed above, and should be labeled as a “Request For Accounting.” D. Right to Request Restrictions You have the right to request a restriction on the health information I use or disclose about you for treatment, payment or health care options. You may also ask that any part (or all) of your health information not be disclosed to any family members or friends who may be involved in your care or for notification purposes as described in Section II (B)(2) of this Notice of Privacy Practices. Request must be sent in writing to the therapist’s office address, listed above. I will honor this request unless the restricted information requested is needed to provide emergency treatment. D. Right to Request Confidential Communications. You have the right to request that I communicate with you about your health care only in a certain location or a certain method, for example, by phone, email or at work. Requests of this nature must be made in writing as indicated previously. No reason for request is required. E. Right to a Paper Copy of this Notice. You have a right to obtain a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this Notice, electronically, you may still obtain a paper copy. V. Confidentiality of Substance Abuse Records. If you have been referred or have received substance abuse treatment or diagnosis due to a drug or alcohol related program, the confidentiality of your substance abuse records is protected by federal law and regulations. As a general rule, I may not disclose this information to a third party unless: - you authorize the disclosure in writing - it is permitted by court order - it is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation purposes; or - you threaten to commit a crime either at the substance abuse program against any person who works for such program. My violation of the federal law and regulations governing drug and alcohol abuse is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs. Federal law and regulations governing confidentiality of substance abuse (drug and alcohol) abuse permit this therapist to report suspected child abuse or neglect under state law to appropriate state & local authorities. Please see 42 U.S.C. ~ 290dd-2 for federal law and 42 C.F.R., Part 2 for federal regulations governing the confidentiality of alcohol and drug abuse patients. II. Complaints If you believe your privacy rights have been violated, you may file a complaint with this therapist or with the Secretary of Health and Human Services. To file a complaint, please write to the address listed above regarding your complaint, and we may set up a meeting to address your concern. III. Changes to this Notice I reserve the right to change the terms of this Notice of Privacy Practices, and incorporate that change with all health information already obtained, as well as health information in the future. You may request a copy of these changes, and should do so in writing to the address listed above, or at our next appointment.