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.