NOTICE OF PRIVACY PRACTICES
Effective January 3, 2022
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
I am required by law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information (Protected Health Information or PHI). I will follow the privacy practices that are described in this Notice. If I amend this Notice, I will provide you with the amended Notice for your information and signature. For more information about my privacy practices, or for additional copies of this Notice, please let me know your questions as soon as they arise.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Permissible Uses and Disclosures Without Written Authorization. I may use and disclose your PHI without your written authorization for certain purposes as described below. The examples provided in each category are not all-inclusive but they describe legally permissible types of uses and disclosures of your mental health information.
Treatment: I may use and disclose your PHI to other clinicians involved in your care in to better provide integrated treatment to you. For example, to maintain quality of care, I may discuss your diagnosis and treatment plan with your primary care provider, psychiatrist, nurse practitioner or other health care practitioners.
Payment: I may use or disclose your PHI for the purposes of determining coverage, billing, claims management, and reimbursement. For example, a bill sent to your health insurer may include some information about our work together so that the insurer will pay for the treatment. I may also inform your health plan about a treatment you are going to receive io determine whether the plan will cover the treatment.
Health Care Operations: I may use and disclose your PHI in connection with health care operations, including quality improvement activities, training programs, accreditation, certification, licensing, or credentialing activities. For, example, I may disclose disguised information about our work for training purposes.
Required or Permitted by Law: I may use or disclose your PHI when required or permitted to do so by law. For example, I may disclose your PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. I may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: public health activities; health oversight activities including disclosures to state or federal agencies authorized to access your PHI; to judicial and law enforcement officials in response to a court order or other lawful process; workers’ compensation claims; military or national security agencies; coroners, medical examiners, or correctional institutions as authorized by law.
PERMISSIBLE USES AND DISCLOSURES THAT MAY BE MADE WITHOUT AUTHORIZATION
YOU HAVE AN OPPORTUNITY TO OBJECT
Additional Services: I may use your PHI to contact you to offer you new services.
Family and Other Persons Involved in Your Care. I may use or disclose your PHI to notify of, assist in notifying, identifying, or locating your personal representative or another person responsible for your care, your location, general condition, or death. If you are present, I will provide you an opportunity to object prior to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose your PHI consistent with your prior expressed preference, and in your best interest as determined by my professional judgment. I will also use my professional judgment and my experience to make reasonable inferences of your best interest before allowing another person access to your PHI regarding your treatment with me.
Disaster Relief. I may use or disclose your PHI to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.
USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION
Psychotherapy Notes. Typically, I do not maintain psychotherapy notes separate from the medical record, but if I were to do so, would not disclose such records, except as permitted by law.
Marketing Communications; Sale of PHI. I do not sell or use for marketing purposes your PHI, but if I were to do so, must obtain your prior written authorization, consistent with the related definitions and exceptions set forth in HIPAA.
Other Uses and Disclosures. Uses and disclosures other than those described in this Notice will only be made with your written authorization. For example, you will need to sign an authorization form before I can send your PHI to your life insurance company or to your attorney. You may revoke any such authorization at any time by providing me with written notification of such revocation.
YOUR INDIVIDUAL RIGHTS
Inspect and Copy. You may request access to your medical records and billing records, inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested.
Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Request Restrictions. You have the right to request a restriction on your PHI that I use or disclose for treatment, payment, or health care operations. You must request any such restriction in writing addressed to Jennie L. Barnes, LCSW, 325 Main St., Suite 155, Waterville, ME 04901 or fax to 844-450-1757. I am not required to agree to any such restriction you may request, except if your request is to restrict disclosing your PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the PHI pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.
Accounting of Disclosures. Upon written request, you may obtain an accounting of disclosures of your PHI made by me in the last six years, subject to certain restrictions and limitations.
Request Amendment: You have the right to request that I amend your PHI. Your request must be in writing and should explain why the information should be amended. I may deny your request under certain circumstances.
Obtain Notice. You have the right to obtain a paper copy of this Notice for your records and you are encouraged to print and maintain this Notice. To obtain a copy with my signature, please submit a written request to Jennie L. Barnes, LCSW, 325 Main St., Suite 155, Waterville, ME 04901 or fax to 844-450-1757 at any time.
Receive Notification of a Breach. I am required to notify you if I discover a breach of your unsecured PHI, according to requirements under federal law.
Questions and Complaints. If you desire further information about your privacy rights or are concerned that I have violated your privacy rights, please contact me at 207-649-4790. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint.
CHANGES TO THIS NOTICE
I may change the terms of this Notice at any time. If the Notice is changed, the new terms may be effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will share it with you through TherapyPortal or other secure communication system in effect at that time. You may also obtain any revised notice by asking me directly.
Revised 01/01/2022
