PRIVACY
NOTICE OF
Brad
Lombardi Counseling (BLC)
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) that prescribes
legal duties and privacy practices to protect the privacy of your individual
identifiable health information; this is, Protected Health Information (PHI),
as that term is defined in the HIPAA under Information.
THE EFFECTIVE DATE OF THIS NOTICE IS APRIL 14, 2003. BLC is required to follow the terms of this
Notice until it is replaced. BLC may
make changes to the terms of this Notice at any time. Upon your request, we will provide you
with a copy of the current Notice. BLC
reserves the right to make the changes apply to your Information
maintained in my files before and after the effective date of the new
Notice. The following is a general
description of how Federal and State law permits me to use and disclose your Information.
Purposes for which BLC May Use or Disclose Your Mental
Health Information with your Consent
BLC may request your consent for the
use and/or disclosure of your Information for treatment, payment
or health care operations as described below:
·
Treatment.
BLC will use and disclose your Information to provide,
coordinate, or manage your mental health care and any related services. BLC may disclose your Information to
physicians, therapists, other mental health providers, or other health care
providers who are treating you or assisting in your diagnosis, treatment, or
recovery.
·
Payment.
Your Information will be used and disclosed, as needed, to obtain
payment for your mental health care services.
This may include certain activities that your health insurance plan
undertakes before it approves or pays for the mental health care services we
recommend for you, such as making a determination of eligibility or coverage
for insurance benefits, reviewing services provided to you for medical
necessity, and utilization review activities.
If more than one, third party payer is responsible for payment for your
health care, BLC may disclose your Information to more than one health
plan and those health plans may share your Information with each
other. Your Information may also
be used and disclosed as needed to obtain payment for mental health care
services rendered to you by other providers.
·
Mental Health Care Operations. BLC may use or disclose, as needed, your Information
in order to support my delivery of mental health care services. BLC may call
you by name in the waiting room area. BLC
may use or disclose your Information, as necessary, to contact you to
schedule an appointment or remind you of your appointment.
BLC may share your Information with third party
Business Associates who perform various administrative services. For example: those within BLC, or with whom BLC
contracts, who perform billing services, transcription services, record
retention, or other professional consultants.
Whenever an arrangement between a Business Associate and BLC involves
the use or disclosure of your Information, BLC will have a written
contract that contains terms that will protect the privacy of your Information.
Health Care Services. Your Information may be used and
disclosed to contact you and to give you information about treatment
alternatives or other health benefits and services that may be of interest to
you.
Your Information may be disclosed to a family member,
friend, or other person designated by you or as designated by the law, if you
verbally agree.
Except as provided below, your Information will not
be used for any non-routine purposes unless you give your written authorization
to do so. If you give written
authorization to use or disclose your Information for a purpose that is
not described in this Notice, then, with certain exception, you may revoke it
in writing at any time. Your revocation
will be effective for the Information BLC maintains, unless BLC has
taken action in reliance on your authorization.
·
As required by law;
·
To comply with legal proceedings, such as a court or
administrative order or subpoena;
·
To law enforcement officials for limited law
enforcement purposes;
·
To a coroner, medical examiner, or funeral director
about a deceased person;
·
To avert a serious threat to your health or safety or
the health or safety of others;
·
To a governmental agency authorized to oversee the
mental health care system or government programs;
·
To federal officials for lawful intelligence,
counterintelligence, and other national security purposes; and
·
To public mental health authorities for public health
purposes.
You may make a written request to BLC to do one or more of
the following concerning your Information:
·
Put additional restrictions on use and disclosure of
your Information.
·
Communicate with you in confidence about your Information
by a different means than BLC is currently doing.
·
See and get copies of your Information.
·
Receive a list of disclosures of your Information
that BLC has made for certain purposes for six (6) years prior to your request
(after April 14, 2003), with certain exceptions permitted by law, which
includes exceptions for disclosure made directly to you or made pursuant to
your authorization.
If you want to exercise any of these rights or require
further information about privacy practices, please contact us at the address
below. In certain instances, BLC is not
required to agree to your request. BLC
will give you the necessary information and forms for you to complete and
return to request your Information.
BLC is permitted, by law, to charge you a fee for copying any documents
requested in accordance with your rights as listed above. (Fee $1.00 per page.)
If you believe that BLC violated your privacy rights, you
have the right to complain to us or to the Secretary of the U.S. Department of
Health and Human Services (DHHS). You
may file a written complaint with us at the address below. An individual must file a complaint within
180 days of when he/she knew or should have known that the act or omission
occurred, unless the time limit is waived by the Secretary of DHHS. BLC will not retaliate against you if you
choose to file a complaint.
Contact Address:
Brad Lombardi Counseling
4730 South National, Suite B-1
Phone: 417-894-0103