Notice of Privacy Practices for Protected Health Information

THIS FORM IS FOR INFORMATIONAL PURPOSES ONLY. DO NOT SUBMIT THIS FORM. PLEASE KEEP A COPY FOR YOUR RECORDS.

This Notice of Privacy Practices describes how the staff of Comprehensive Mental Health Services may generate, use and disclose your protected health information for purposes of treatment, payment and the maintenance of healthcare operations as allowed by law. Protected health information is the information we create and collect in providing you services. Such information may include an initial evaluation, descriptions of symptoms, treatment plans, progress notes, test results, diagnoses, and applications for future care or treatment. It also includes documents used for billing.

The following examples are not meant to be exhaustive:

Examples of using your health information for treatment purposes:

• An employee of Comprehensive Mental Health Services obtains treatment information about you and records it in a health record.
• Often your clinician will consult with colleagues in our office about your situation and condition: sometimes informally, in supervision, or in a case presentation for the entire clinical staff.
• During the course of treatment, your clinician may consult with another healthcare provider already involved in your care. As part of this consultation, your personal health information is disclosed.
• During the course of treatment, Comprehensive Mental Health Services receives information from school personnel, family members, legal counsel, clergy, law enforcement personnel, etc.
• During the course of treatment, clinical and/or clerical staff discloses personal health information to your pharmacist.

Examples of using your health information for payment purposes are:

• We mail a bill to your home.
• We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding services rendered. We provide that information in order that you may be reimbursed.
• We verify insurance coverage prior to your first appointment and obtain prior authorization and pre-certification when required to do so by your policy coverage.

Examples of using your health information for healthcare operations are:

• A member of our staff contacts you at home, at work or elsewhere in order to schedule an appointment, confirm an appointment of in reply to a message.
• A member of our staff transmits your personal health information via fax machines.
• Clerical staff conveys messages, produces letters, reports and notes containing personal health information.
• A federal or state licensing authority wants to review our records to assure that we are in compliance with regulations relevant to our practice. Towards this end, the government authority requests a sampling of our records which includes your chart. At the licensing authority's request, we will provide it with a copy of your chart.

You health information rights:

The health record and billing records we maintain are the physical property of this office. However, the information contacted in the records belongs to you. You have a right to:

• Request a restriction on certain uses and disclosures of your protected health information by delivering the request in writing to our office. While we are not required to grant all requests, we are bound by any request granted.
• Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office.
• Request that you be allowed to inspect and receive a copy of your health record and billing record. You may exercise this right by delivering the request in writing using the form we provide upon request. Please be aware that you are not necessarily entitled to "psychotherapy notes" or information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding. Also, be aware that with notes on sessions in which treatment is provided to more than one individual (for example, couples treatment or family therapy) all parties involved must consent in order to release that portion of the record. Also of note, while educational and psychological testing evaluations are incorporated into health records, testing protocols - including raw test data - are not.
• Appeal a denial of access to your protected health information.
• Request that your healthcare record be amended to correct incomplete or incorrect information. You may do this by delivering a written request to our office using the form we provide upon request.
• File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your healthcare information.
• Obtain an accounting of disclosures of your healthcare information by delivering a written request to our office using the form we provide upon request. The accounting will not include uses of your information within our office (to facilitate treatment, consultation, payment, or charting) or written disclosures made to you.
• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing using the form we provide upon request.
• Revoke any authorization that you made previously to use or disclose information, except to the extent the information has been disclosed or action has already been taken, by delivering a written revocation to our office.

You have the right to review this Notice before signing the consent authorizing use and disclosure of you protected health information for treatment, payment, and healthcare operations purposes.

If you want to exercise any of the above rights, you may speak with our office staff at ext. 10 or Joel Szkrybalo, PhD, Compliance Officer at ext. 11.

Our Responsibilities

Comprehensive Mental Health Services is required to:

• Maintain the privacy of your health information as required by law.
• Provide you with a notice as to our duties and privacy practices regarding the information we collect and maintain about you.
• Abide by the terms of this Notice.
• Notify you if we cannot accommodate a requested restriction or request for disclosure.
• Accommodate your reasonable requests regarding methods to communicate healthcare information to you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your personal healthcare information, you may contact the following people: Joel Skrybalo PhD, Compliance Officer or Jonathan Woods, Director. Additionally, if you believe your privacy rights have been violated, you may file a complaint by delivering it, in writing, to Joel Szkrybalo PhD, Compliance Officer or Jonathan Woods, Director. You may also file a compliant by mailing or e-mailing it to the Secretary of Health and Human Services.

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint.

Other Uses and Disclosures

Business Associates: We have Business Associates who may come in contact with different aspects of your protected healthcare information (the following examples are not meant to be exhaustive):

• For example, in preparing financial statements and/or preparing tax returns, some portions of your healthcare information may be disclosed to our accounting firm.
• For example, we may need to hire computer technicians and software vendors. Such technicians and vendors may have access to your personal healthcare information in order to maintain daily functioning of our routine healthcare operations.
• For example, in the course of their work, our cleaning service, our landlord, repairmen and/or builders may come in contact with some aspect of your healthcare information.
• For example, when you call our emergency number and communicate with the staff of the answering service - a separate entity from Comprehensive Mental Health Service - you may divulge personal health information.

Please note, our Business Associates sign agreements pledging to respect and protect the confidentiality of any personal healthcare information they may be exposed to in the course of performing their duties.

Communication with Family

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, healthcare information relevant to that person's involvement in your care or payment for such care if you do not object, or in an emergency.

Disaster Relief

We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors/Coroners

We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Marketing

We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits or services that may be of interest to you.

Workers' Compensation

If you are seeking compensation through Workers' Compensation, we may disclose your protected healthcare information to the extent necessary to comply with laws related to Workers' Compensation.

Public Health

As required by law, we may disclose your protected healthcare information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse and Neglect

We may disclose your protected healthcare information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law purposes as required by a court order.

Health Oversight

Federal law allows us to release your protected healthcare information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected healthcare information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Consistent with applicable law, we may disclose your protected healthcare information to prevent or lessen a serious, imminent threat to the health or safety of a person or to the public.

For Specialized Governmental Functions

We may disclose your protected health information for specialized government functions as authorized by law such as Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses

Other uses and disclosures in addition to those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke that authorization as previously stated.