Notice of Privacy Practices
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 THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics (National Association of Social Workers). It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with the notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.
To promote quality of care, I use an electronic health record system. This electronic health record lets me look at and/or add information about you, your health, the care you receive, and other important facts. I cannot remove information once it is placed in the electronic health record.
For Payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment related activities are: Making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to a lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operation: I may use or disclose, as needed, your PHI in order to support my businesses activities including, but not limited to, quality assessment activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
Appointment reminders: I may send you an email and/or text message for appointment reminders. You can opt-out of this service.
Newsletter: I may send you my newsletter via email if you request to receive it. You can opt-out of this.
Email: I may coordinate with you by email only with your approval. If you change your mind, you may advise me in writing at 171 Lawrence St. #7, Eugene OR 97401.
Required by law: Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Without Authorization: Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations.
As a social worker licensed in this state and as a member of the National Association of Social Workers, it is my practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.
Child or Elder Abuse or Neglect: I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child or elder abuse or neglect.
Judicial and Administrative Proceedings: I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
Deceased Patients: I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin.
Medical Emergencies: I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
Family Involvement in Care: I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
Health Oversight: If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer reviewed organizations performing utilization and quality control.
Law Enforcement: I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with the deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions: I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.
Public Health: If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
Public Safety: I may disclose your PHI if necessary, to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
COVID-19 Disclosures to a Public Health Authority: PHI may be disclosed to a public health authority such as the CDC or a state or local health department without your authorization. Disclosures may be made on an ongoing basis as needed to report all prior and prospective cases of patients exposed to or suspected or confirmed to have COVID-19.
Disclosures to Persons at Risk of Contracting or Spreading COVID-19: PHI may be disclosed to a person who may have been exposed to COVID-19 or may be at risk of contracting or spreading COVID-19 if I am authorized by law to make such notifications to prevent or control the spread of the disease or to carry out a public health intervention or investigation.
Disclosures to Prevent or Lessen a Serious and Imminent Threat of COVID-19: I may disclose protected health information based on my good faith belief that the disclosure is necessary to anyone who is in a position to prevent or lessen a serious and imminent threat to the health or safety of a person or the public due to COVID-19, including family, friends, caregivers and law enforcement without your permission.
Research: PHI may only be disclosed after a special approval process or with your authorization.
Verbal Permission: I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made use or disclosed based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes with are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communication; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these right, please submit your request in writing to Jolene Nell, LICSW, LCSW at 171 Lawrence St. #7, Eugene, OR 97401.
- Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes or if the PHI is from a different provider that has been supplied to me. I may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
- Right to Amend: If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
- Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service paid for out of pocket. In that case, I am required to honor your request for restriction.
- Right to request Confidential Communication: You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request.
- Breach Notification: If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a copy of this Notice: You have a right to a copy of this notice.
If you believe your privacy rights have been violated, you may file a complaint in writing to Jolene Nell, LICSW, LCSW at 171 Lawrence St. #7, Eugene, OR 97401 or with the Secretary of the Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201 or by calling (877) 696-6775. I will not retaliate against you for filing a complaint.
EFFECTIVE DATE OF THIS NOTICE
This effective date of this Notice is May 26, 2020.
RECEIPT AND ACKNOWLEDGMENT OF NOTICE
BY SIGNING BELOW, I HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED AND HAVE BEEN GIVEN AN OPPORTUNITY TO READ A COPY OF JOLENE NELL, LICSW, LCSW’S NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT IF I HAVE ANY QUESTIONS REGARDING THIS NOTICE OR MY PRIVACY RIGHTS, I CAN CONTACT JOLENE NELL, LICSW, LCSW AT 171 LAWRENCE ST. #7, EUGENE, OR 97401 OR BY CALLING 541-505-3533.
Signature: _____________________________________ Date: _______________