Notice of Privacy Practices (Brief Version)
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.
Commitment to your privacy
I am dedicated to maintaining the privacy of
your personal health information (PHI) as part of providing professional care. I am also required by law to keep your
information private. These laws are
complicated, but I must give you this important information. This is a shorter version of the attached,
full, legally required notice of privacy practices.
How I use and disclose your protected health
information with your consent
I will use the information I collect about
you mainly to provide you with treatment, to arrange payment for
the services, and for some other business activities that are called, health
care operations. After you have read
this notice, I will ask you to sign a consent form to let me use and
share your information in these ways. If
you do not consent and sign this form, I cannot treat you. If I want to use, send, share, or release your
information for other purposes, I will discuss this with you and ask you to
sign an authorization form to allow this.
Disclosing your health information without
your consent
There are some times when the laws require us
to use or share your information. For example:
1. When there is a serious threat to your or
another’s health and safety or to the public. We will only share information
with persons who are able to help prevent or reduce the threat.
2. When we suspect or have knowledge that a
child is being abused.
3. When we are required to do so by lawsuits
and other legal or court proceedings.
4. If a law enforcement official requires us
to do so.
5. For workers’ compensation and similar
benefit programs.
There are also some other rare situations.
They are described in the longer version of the notice of privacy practices.
Your rights regarding your health information
1. You can ask me to communicate with you in
a particular way or at a certain place that is more private for you. For example, you can ask me to call you at
home, and not at work, to schedule or cancel an appointment. I will try my best to do as you ask.
2. You can ask me to limit what I tell people
involved in your care or the payment for your care, such as family members and
friends.
3. You have the right to look at the health
information I have about you, such as your medical and billing records. You can get a copy of these records, but I may
charge you for it.
4. If you believe that the information in
your records is incorrect or missing something important, you can ask me to
make additions to your records to correct the situation. You have to make this request in writing and
send it to the privacy officer. You must
also tell me the reasons you want to make the changes.
5. You have the right to a copy of this
notice. If I change this notice, I will
post the new version in our waiting area, and you can always get a copy of it
from the privacy officer.
6. You have the right to file a complaint if
you believe your privacy rights have been violated. You can file a complaint
with our privacy officer and with the Secretary of the U.S. Department of
Health and Human Services. All
complaints must be in writing. Filing a
complaint will not change the health care I provide to you in any way. Also, you may have other rights that are
granted to you by the laws of our state, and these may be the same as or different
from the rights described above. I will
be happy to discuss these situations with you now or as they arise. If you have
any questions regarding this notice or our health information privacy policies,
please contact the privacy officer, who is Elo
Pranno MSW, LCSW and can be reached by phone at 724-699-6538.
The notice is effective immediately.
My signature below indicates that the Notice
of Privacy Policy was explained to me in detail. I had the opportunity to ask questions and
receive clarification on any part of this policy. Further, I received an unabridged copy of
this policy.
Client/Guardian Signature Date
Clinician Signature Date