This Notice explains in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice’s legal duties with respect to my protected health information.
· This practice is required by law to maintain the privacy of protected health information.
· We are required to abide by the terms of the Privacy Practice Notice currently in effect; and
· We must disclose protected health information in only two (2) situations: (a) to the individual “you” (or your personal representatives “a person legally authorized to make health care decisions” such as a parent, guardian, power of attorney) specifically when they request access to, or an accounting of disclosures of their protected health information; and (b) to the U.S. Department of Health and Human Services (HHS) when it is undertaking a compliance investigation or review or enforcement action.
· My individual rights with respect to protected health information have been defined and a brief description of how you may exercise these rights in relation to:
o You have the right to complain to this practice if you believe your privacy rights have been violated. No retaliatory actions will be used against you in the event of such a complaint. If you believe your privacy rights have been violated, the point of contact is Dana Wojciechowski, the Privacy Officer, 570-489-5561 x1032. You will be contacted within 7 business days.
o You have the right to request restrictions on certain uses and disclosures of your protected health information, however, we are not required to agree for specific reasons. You may request restrictions of use and disclosure related to treatment, health care operations, and payment. You may request restrictions if we implement a facility directory that is an internal tracking system. You may request restrictions to members of your family or others involved in your care. However, a request for a restriction regarding treatment that is paid for out-of-pocket and in full and the disclosure would be solely for payment of health care operations purposes to a health care plan. Example, you may consent for us to speak with your family, but not discuss certain conditions or treatment.
o You have the right to receive “confidential communications” of protected health information. Typically, we leave messages on the phone numbers, emails, and addresses you provide to us. Please note there is an implicit understanding when you give us contact information for communications you agree to allow us to leave basic information regarding appointments, results or to answer questions you may have asked. To request a confidential communication please contact the front desk, your treatment provider or a supervisor.
o You have the right to inspect and copy protected health information. To request to inspect and copy your protected health information, the point of contact is Rebekah Nazarchuk, Clinical Supervisor, 570-489-5561 x1041. You may incur a copying charge.
o You have the right to amend protected health information when the information is inaccurate or incomplete. For an amendment request, the point of contact is Rebekah Nazarchuk, Clinical Supervisor, (570) 489-5561 x1041. When we accept an amendment request, we will make reasonable efforts to provide the amended information to the persons you have identified as needing it and to persons we know might rely on the information otherwise without it would be a detriment. If the amendment request is denied, we will allow you to submit a statement of disagreement that will be included in your record.
o You have the right to receive an accounting of disclosures of protected health information. To request the disclosure, the point of contact is Rebekah Nazarchuk, Clinical Supervisor, 570-489-5561 x1041. We will keep the disclosures for a period of six years.
o You have the right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.
Your protected health information may be used and disclosed without your permission in certain circumstances, in other circumstances your protected health information will not be used or disclosed unless you sign and authorization to do so. You may revoke authorization at any time.
1. Permitted Uses and Disclosures of My Protected Health Information
Permitted uses and disclosures of your protected health information that do not need a consent or authorization for most uses are listed below.
To the Individual. We may disclose protected health information to the individual (you) who is the subject of the information. Example, the Aaron Center provides you with a copy of your Intake Evaluation.
PLEASE NOTE: RECORDS USED FOR ANY LEGAL PURPOSE BECOME PUBLIC RECORD AND MAY
BE POSTED ONLINE BY COUNTY OFFICIALS. PLEASE CONSIDER THIS BEFORE PROVIDING THEM FOR LEGAL PURPOSES.
Treatment is the provision of services, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another. Example, the Aaron Center coordinating care with your primary care doctor, or to another provider such as a pediatrician.
Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual. Example, your health care provider may request supporting documentation from the Aaron Center.
Health care operations are any of the following activities: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities. Example, a review of your protected health information may be conducted by your insurance company.
Uses and disclosures with opportunity to Agree or Object. There are times when we will request, or you will request information be provided to others verbally. You may give informal permission by telling us directly to release information. We may also request informal permission to use or disclose PHI and you have the right to agree or object. However, we are permitted to use and disclose protected health information in emergency situations and internal directories within the Agency.
Incidental use and disclosure. The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. We may use or disclose information that occurs as a result of, or as “incident to,” an otherwise permitted use or disclosure and is permitted as long as we have adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the “minimum necessary,” as required by the Privacy Rule.
Public Interest and Benefit Activities. We are required and permitted to use and disclose protected health information without written consent or authorization for 12 national priority purposes. These disclosures are permitted, although not required, by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest need for this information.
Required by Law. We may use and disclose protected health information without individual authorization as required by law (including by statute, regulation, or court orders).
Public Health Activities. We may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post-marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law. Example, CDC.
Victims of Abuse, Neglect or Domestic Violence. In certain circumstances, we may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence. Example, Women’s Resource Center.
Health Oversight Activities. We may disclose protected health information to health oversight agencies (as defined in the Rule) for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs. Example, Office of Mental Health & Substance Abuse.
Judicial and Administrative Proceedings. We may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided. Example, family law, or criminal law issues.
Law Enforcement Purposes. We may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if the covered entity suspects that criminal activity caused the death; (5) when a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime. Example, locating a suspect or fugitive.
Decedents. We may disclose protected health information to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law. Example, a funeral director may need assistance to identify a person who has died.
Cadaveric Organ, Eye, or Tissue Donation. We may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs, eyes, and tissue.
Research. “Research” is any systematic investigation designed to develop or contribute to generalizable knowledge. The Privacy Rule permits the Aaron Center to use and disclose protected health information for research purposes, without an individual’s authorization, provided the covered entity obtains either: (1) documentation that an alteration or waiver of individuals’ authorization for the use or disclosure of protected health information about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use or disclosure of the protected health information is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any protected health information from the covered entity, and that protected health information for which access is sought is necessary for the research; or (3) representations from the researcher that the use or disclosure sought is solely for research on the protected health information of decedents, that the protected health information sought is necessary for the research, and, at the request of the Aaron Center, documentation of the death of the individuals about whom information is sought. We also may use or disclose, without an individuals’ authorization, a limited data set* of protected health information for research purposes. Example, research when the information has been approved with deidentified data. Example, when the patient authorizes to participate in research with a data use agreement.
Serious Threat to Health or Safety. Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat). Covered entities may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal. Example, to authorities or other person who is in immediate danger.
Essential Government Functions. An authorization is not required to use or disclose protected health information for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs. Example, the US government may require it due to an essential military mission.
Workers’ Compensation. We may disclose protected health information as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses. Example, an injury at your workplace.
*Limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set. You will be asked to sign a DATA SET AUTHORIZATION prior to the use or disclosure of the PHI.
2. Uses and Disclosures of Protected Health Information That You Must Authorize
We must obtain an individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule. We may not condition treatment, payment, enrollment, or benefits eligibility on an individual granting an authorization, except in limited circumstances.
You must authorize a third party to receive protected health information. It may allow use and disclosure of protected health information by the Aaron Center seeking the authorization, or by a third party. Examples, a life insurer for coverage purposes or disclosures to an employer of the results of a pre-employment physical.
Psychotherapy Notes. You must sign an authorization to release Psychotherapy Notes. We must obtain an individual’s authorization to use or disclose psychotherapy notes with the following exceptions:
· We may use or disclose psychotherapy notes generated and originated in our practice for treatment.
· We may use or disclose, psychotherapy notes, for our own training.
· We may use or disclose psychotherapy notes to defend ourselves in legal proceedings brought by the individual, for HHS to investigate, or to determine our compliance with the Privacy Rules
· We may use or disclose psychotherapy notes to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight of the originator of the psychotherapy notes, for the lawful activities of a coroner or medical examiner or as required by law.
PLEASE NOTE: RECORDS USED FOR ANY LEGAL PURPOSE BECOME PUBLIC RECORD AND MAY BE POSTED ONLINE BY COUNTY OFFICIALS. PLEASE CONSIDER THIS BEFORE PROVIDING THEM FOR LEGAL PURPOSES.
Marketing. Marketing is any communication about a product or service that encourages recipients to purchase or use the product or service. The Privacy Rule carves out the following health-related activities from this definition of marketing:
· Communications to describe health-related products or services, or payment for them, provided by or included in a benefit plan of the covered entity making the communication.
· Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan’s enrollees that add value to, but are not part of, the benefits plan.
· Communications for treatment of the individual; and
· Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, health care providers, or care settings to the individual.
3. Limiting Uses and Disclosures to the ‘Minimum Necessary”
We have developed safeguards to control access to and limit uses and disclosures of protected health information by a number of methods using the minimum necessary standard.
Minimum Necessary. A central aspect of the Privacy Rule is the principle of “minimum necessary” use and disclosure. We will make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish our intended purpose of the use, disclosure, or request.
The minimum necessary requirement is not imposed in any of the following circumstances
(a) disclosure to or a request by a health care provider for treatment
(b) disclosure to an individual who is the subject of the information, or the individual’s personal representative
(c) use or disclosure made pursuant to an authorization
(d) disclosure to HHS for complaint investigation, compliance review or enforcement
(e) use or disclosure that is required by law
(f) use or disclosure required for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules.
Access and Uses. For internal uses, we restrict access to and uses of protected health information based on the specific roles of the members of our workforce.
Disclosures and Requests for Disclosures. We have established and implemented policies and procedures for routine, recurring disclosures, or requests for disclosures, that limits the protected health information disclosed to that which is the minimum amount reasonably necessary standard.
Reasonable Reliance. When you authorize a third party to obtain protected health information from us, it is assumed the request as complying with the minimum necessary standard. Similarly, we may rely upon requests as being the minimum necessary protected health information from: (a) a public official, (b) a professional (such as an attorney or accountant) who is our business associate, seeking the information to provide services to or for us; or (c) a researcher who provides the documentation or representation required by the Privacy Rule for research.
4. Breach Notification
Security Breach. A breach is defined as the acquisition, access, use, or disclosure of protected health information in a manner not permitted which compromises the security or privacy of the protected health information. In the event of a security breach, individuals will be informed in writing. At the end of the calendar year HHS will be notified as well. If the breach included more than 500 individuals, HHS and the media will be notified according to HIPAA standards.
5. Fundraising Campaign
Fundraising. We may contact you or send you communications to raise funds. You have the right to opt-out of receiving such communications.
This practice reserves the right to change the terms of this Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. If changes occur, this practice will provide me a revised Notice of Privacy Practices upon request and it is posted in the center.