Still Waters Family Counseling is committed to protecting the privacy of your medical, mental health and substance abuse information. We create a record of the care and services that you receive from us. This information is needed to provide you with quality care and to comply with legal and ethical standards. We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices. We are also required to comply with the terms of this notice. This Notice of Privacy Practices contains an outline of your rights regarding the information that we maintain about you and a description of how you may exercise these rights. This notice also describes how we may use or disclose your Protected Health Information to carry out treatment, obtain payment or for healthcare operations, and for other purposes that are permitted or required by law. The Health Information Portability and Accountability Act (HIPAA) defines ‘Protected Health Information’ as medical, mental health, and substance abuse information, including identifying information about you that we have collected from you or received from others. This Notice of Privacy Practices applies to all Still Waters Family Counseling providers, staff members, and student interns
You have the following rights regarding your Protected Health Information (PHI). You have a right to:
Still Waters Family may use or disclose your Protected Health Information (PHI) for treatment, payment or healthcare operations.
Uses and Disclosures of your Protected Health Information (PHI) That May Be Made Only with Your Specific Authorization
Uses and Disclosures of your Protected Health Information (PHI) That May Be Made Without Your Authorization
If you believe that your rights have been violated, contact our office to discuss the issue or contact the Office of Civil rights. Your services will not be affected in way if you file a complaint.
To file a complaint with the Office of Civil Rights, call or write:
Office of Civil Rights US Dept. of Health and Human Services 200 Independence AVE, S.W. Washington DC 20201 1-877-696-6775 OCRPrivacy@hhs.gov
I,
acknowledge that I have received a copy of Still Waters Family Counseling’s Notice of Privacy Practices. My signature below indicates that I have received the Notice of Privacy Practices and that I have been provided an opportunity to ask questions about office’s privacy practices as they pertain to my Protected Health Information.
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