THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (this "Notice")
of LIFE TREE Counseling Center ("LIFE TREE")
is being provided to you in accordance with the requirements
of the Standards for Privacy of Individually Identifiable
Health Information of the Health Insurance Portability
and Accountability Act (the "HIPAA Privacy Rules").
The HIPAA Privacy Rules are federal laws that seek
to ensure the privacy and confidentiality of your
health information. This notice has been prepared
to advise
you of the uses and disclosures of your Protected
Health Information that may be made by LIFE TREE
and to advise
you of your rights and LIFE TREE’S legal duties
relating to the privacy of your Protected Health
Information (henceforth referred to as "PHI").
In referring to "Health Care" in this document
it is understood we are also referring to "Mental
Health Care".
The law permits LIFE TREE to use or disclose PHI to
carry out "treatment", "payment" and
other "daily office operations". LIFE TREE
is not required to obtain an authorization from you
or notify you each time it uses or discloses your
PHI for treatment, payment or health care operations
purposes.
Treatment: "Treatment" means the
provision, coordination, or management of health
care and related
services by health care providers, including the
coordination or management of health care by a health
care provider
with a third party (such as an insurer of LIFE TREE),
consultation between providers with respect to a
patient, and the referral of a patient for health
care from
one provider to another. LIFE TREE may disclose PHI
to your Primary Care Physician, or to another physician
to whom you have been referred to ensure that the
physician has the necessary information to diagnose
or treat
you.
Payment: Your PHI will be used, as needed, to
obtain "payment" for
your health care services provided by LIFE TREE.
This may include certain activities that your health
insurance
plan may undertake before it approves or pays for
the services LIFE TREE recommends for you such as
making
a determination of eligibility or coverage for insurance
benefits, and undertaking utilization review activities
necessary to obtain precertification for services
("Sessions").
PHI may be disclosed to your health care plan to
obtain approval for hospitalization as well.
Daily Office Operations: These are those other
functions and activities that LIFE TREE performs
in connection
with providing health care. These activities include,
but are not limited to quality assessment activities,
training of psychology students, credentialing, underwriting,
auditing functions, budgeting and financial reporting,
and conducting or arranging for other business and
administrative activities. In addition, LIFE TREE
may use a sign-in sheet at the registration desk
where
you will be asked to put your first name and indicate
your Therapist. LIFE TREE may also call you by name
in the waiting room when your Therapist is ready
to see you. LIFE TREE may share your PHI with third
party "business
associates" that perform various functions (e.g.
billing services) for LIFE TREE Therapists. LIFE
TREE will have a written contract with each business
associate
that contains terms that will protect the privacy
of your PHI.
LIFE TREE may use or disclose your PHI to provide you
with appointment reminders or information about your
treatment alternatives or other health-related benefits
and services that may be of interest to you.
For uses and disclosures of PHI that are not for treatment,
payment, or daily office operations purposes and
for which no exception applies, the law requires
LIFE TREE to obtain your written approval in order
to disclose your PHI to a particular person or
entity for a particular purpose ("Authorization").
You may revoke Authorization at any time, but a
revocation is not effective if LIFE TREE has already reasonably
relied on your Authorization to make a particular
use or disclosure.
The types of uses and disclosures of PHI that may be
made without your Authorization and without giving
you the opportunity to object include these (among
others): for public health activities; for FDA-related
purposes; to address work-related illness/injuries
and for worker's compensation purposes (such as when
the Government requests certain information from
LIFE TREE to determine its compliance with applicable laws):
when a judge or administrative tribunal orders the
release of PHI; to properly assist law enforcement
agencies to carry out their duties; pursuant to a
request
from a law enforcement official if the individual
is a victim of a crime; for purposes of identifying or
locating a suspect, fugitive, material witness, or
missing person; for reporting to correctional institutions/law
enforcement officials acting in a custodial capacity;
and for certain military/security purposes.
There are several types of uses or disclosures of PHI
that LIFE TREE may make without your Authorization
as long as, whenever possible you are given the opportunity
to agree or object before LIFE TREE makes the disclosure.
These exceptions are very limited and generally involve
the release of a limited amount of PHI, and include,
but are not limited to the following purposes: to
aid
family members, close personal friends or persons
identified by you to assist in your care, payment of care;
or
to aid them in locating you and notifying them of
your condition. In these circumstances, LIFE TREE will make
a concerted effort to obtain your Authorization prior
to making these disclosures.
You have the right to request additional restrictions
relating to LIFE TREE'S use or disclosure of your
PHI beyond those otherwise required under the HIPAA Privacy
Rules. Although LIFE TREE is not legally required
to
grant these requests, it is your right to make such
a request. To obtain the proper form for making such
a request, please ask your Therapist.
LIFE TREE may communicate your PHI to you in a variety
of ways, including by mail or telephone.
Subject to certain limitations, you have the right
to request and obtain access to inspect and to copy
your PHI maintained by your LIFE TREE Therapist unless
the information is not required to be accessible
under the HIPAA Privacy Rules or other applicable law. LIFE
TREE does not have to disclose (to you) the release of
your
PHI to law enforcement officials, correctional institutions,
and other federal agencies.
LIFE TREE may charge you a reasonable, cost-based fee
for copying (including the cost of supplies and labor)
any PHI required to be copied to adequately respond
to your access request, as well as any postage costs
and costs associated with preparing an explanation
or summary of the PHI necessary to meet your request
(unless otherwise precluded by applicable State or
other law). Please notify your Therapist to obtain
the appropriate forms. You have the right to request
that LIFE TREE amend your PHI. LIFE TREE reserves
the right to deny or partially deny requests for amendments
that are not required to be granted under the HIPAA
Privacy Rule. If you would like to request an amendment
of you PHI, please notify your Therapist so that
you can complete the appropriate form.
You have the right to request and obtain an accounting
of disclosures that LIFE TREE has made of your PHI
in the six years prior to the date on which the accounting
is requested. LIFE TREE is not required to provide
an
accounting of disclosures made for treatment, payment,
or daily office operations or for disclosures made
without your Authorization. Also, LIFE TREE reserves
the right to limit its accountings to disclosures
made after the compliance date of the HIPAA Privacy Rules.
LIFE TREE may change the terms of this Notice at any
time. The new notice will be effective for all PHI
that LIFE TREE maintains at that time. Upon your
request LIFE TREE will provide you with any revised Notice
of
Privacy Practices. You may request this Notice from
your LIFE TREE Therapist.
If you have any questions or concerns or feel that
LIFE TREE has violated your privacy rights or has
acted inconsistently under the HIPAA Privacy Rules,
you may
file a complaint with your Therapist on the appropriate
form. You may also file a complaint with the Office
of Civil Rights ("OCR") at the United States
Department of Health and Human Services.
It is against the policies and procedures of LIFE TREE
to retaliate against any person who has filed a Privacy
complaint, either with LIFE TREE or with HHS OCR.
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