HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1998 (HIPAA) is a federal program that requires that all medical records and other individual identifiable health information used or disclosed by me in any form, whether electronically, on paper, or orally are kept properly confidential. This act gives you, the client, significant rights to understand and control how you health information is used. HIPAA provides penalties for covered entitle that misuse personal health information.
As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information.
I may use and disclose your medical records only for each of the following purposes:
I may also create and distribute de- identified health information by removing all references to individually identifiable information.
I may contact you to provide appointment reminders or information about treatment alternatives or other health –related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information (PHI), which you can exercise by presenting a written request to me:
I am required by law to maintain the privacy of your PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI.
This notice has been in effect since April 14, 2003, and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of my Notice of Privacy Practices and to make the new notice provisions effect for all PHI that I maintain. I will post, and you may request, a written copy of a revised Notice of Privacy Practices from my office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with me, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my office. I will not retaliate against you for filing a complaint.
Please contact me for more information.
Elaine R. Poncelet, LICSW (401) 294-9500.
For more information about HIPAA or to file a complaint:
The U.S. Dept. of Health and Human Services,
Office of Civil Rights,
200 Independence Ave., S.W.
Washington, D.C. 20201; (202) 619-0257; Toll Free: 1-877-696-6775.