NOTICE OF PRIVACY POLICIES – HIPAA DISCLOSURE

Your Information • Your Rights • Our Responsibilities

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This notice describes how healthcare information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We Have A Legal Duty to Protect Health Information About You
We are required by law to protect the privacy of health information about you and that can be identified with you, which we call “protected health information,” or “PHI” for short. We must give you notice of our legal duties and privacy practices concerning PHI:

  • We must protect PHI that we have created or received about: your past, present, or future health condition; health care we provide to you; or payment for your health care.
  • We must notify you about how we protect PHI about you.
  • We must explain how, when and why we use and/or disclose PHI about you.
  • We may only use and/or disclose PHI as we have described in this Notice.

This Notice describes the types of uses and disclosures that we may make and gives you some examples. In addition, we may make other uses and disclosures which occur as a byproduct of the permitted uses and disclosures described in this Notice. If we participate in an “organized health care arrangement” (an example of an “organized health care arrangement” is the care provided by a hospital and the physicians who see patients at the hospital), the providers participating in the “organized health care arrangement” may share PHI with each other, as necessary to carry out treatment, payment or health care operations relating to the “organized health care arrangement”.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:

  • Posting the revised notice in our offices;
  • Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice); and
  • Posting the revised notice on our website.

SUMMARY

Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you. We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed (and sometimes required) to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Court order. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in, or contemplating, litigation, you should
consult with your attorney to determine whether a court would be likely to order me to disclose
information.

Abuse or neglect. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency.

Threat of harm to others. If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

Threat of harm to self
If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for
him/her or to contact family members or others who can help provide protection.

The situations described above have rarely occurred in my practice. If a similar situation occurs when working with you, I will make every effort to discuss it with you fully before taking any action.

Consultations
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I
make every effort to avoid revealing the identity of my patient. The consultant is also legally bound
to keep the information confidential. If you don’t object, I will not tell you about these consultations
unless I feel that it is important to our work together.

Help with public health and safety issues. We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research. We can use or share your information for health research.

Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Certain Restrictions on Disclosure in North Carolina

Mental Health Treatment
North Carolina law protects the privacy of communications regarding mental health treatment
between you and your mental health provider. Before disclosing mental health information about
you to others for treatment, payment, or health care operations, we will request that you sign a
written form giving us permission to make the disclosure.

Drug Dependency
If you request treatment and rehabilitation for drug dependence from one of our practitioners, your
request will be treated as confidential. We will not disclose your name to any police officer or other
law-enforcement officer unless you consent to our sharing of it. Even if we refer you to another
person for treatment and rehabilitation, we will continue to keep your name confidential.

Minors

Under North Carolina law, minors, with or without the consent of a parent or guardian, have the
right to consent to services for the prevention, diagnosis and treatment of certain illnesses
including: venereal disease and other diseases that must be reported to the State; pregnancy; abuse of controlled substances or alcohol; and emotional disturbance. Regarding abortion services,
however, North Carolina law requires the consent of both the minor and the parent, guardian or a
grandparent with whom the minor has been living for at least six (6) months, unless a court has
determined that the minor alone can consent to the abortion. If you are a minor and you consent to
one of these services, you have all the authority and rights included in this Notice relating to that
service. In addition, the law permits certain minors to be treated as adults for all purposes. These
minors have all rights and authority included in this Notice for all services.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and provide you with a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Effective Date: January 1, 2014

Karen A. Muehl, PhD
Karen Muehl Counseling, PLLC

Rev. 01/2014
4828-4914-3064, v. 2

CONTACT INFO

Dr. Karen Muehl
1616 Cleveland Ave
Suite 102
Charlotte, NC 28203
Phone: 980-202-2033

verified by Psychology Today

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