INFORMATION. PLEASE REVIEW IT CAREFULLY.
DEBORAH S. ZWICK, PH.D. acts to maintain the privacy of protected health information and provide individuals with notice of the practice’s legal duties and privacy practices regarding protected health information as described in this Notice. Our computers have passwords to protect our database, only the minimum necessary information is disclosed, and access of your medical information to our staff is limited to the essentials needed to perform their duties.
Provision of Notice: The practice will provide its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship no later than the date of the first treatment to the patient after June 10, 2003 and post it in the waiting room. This Notice is available via mail to any member of the public to enable prospective patients to evaluate the practice’s privacy practices when making his or her decision regarding seeking treatment from the practice.
Documentation of Provision of Notice: When a patient receives the Notice from the practice, the practice will request they sign their “Receipt of Notice of Privacy Practices” form. The form is filed with the patient’s medical record. Should the patient refuse to sign the form, it will be noted in the record that the patient was given the Notice and refused to sign the form.
Effective Date and Changes to Notice: This Notice is effective June 10, 2003. The practice reserves the right to revise this notice whenever there is a material change to the uses or disclosures, the individual’s rights, the covered entity’s legal duties, or others privacy practices stated in the Notice. If the Notice is revised, it will be available upon request beginning on the revision’s effective date. The revised Notice will be posted in the practice’s reception area and made available to all patients, including those who had previously received their Notice. The patient will then be asked to acknowledge receipt of the updated Notice.
Complaints: If you believe your privacy rights are being violated, you may file a written complaint, describing the acts or omissions within 180 days of becoming aware of the violation. These letters should be addressed to Deborah S. Zwick, Ph.D., privacy officer, at P.O. Box 2870, Edwards, CO 81632. The practice will investigate each complaint. The patient also has the right to contact,
Secretary
U.S. Department of Health & Human Services,
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
The practice will not take any adverse action against any patient who files a complaint against the practice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
My office is permitted by federal law to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing services to you. It may include documenting your symptoms, psychological examination, and test results, diagnoses, treatment and recommendations for future care or treatment. It also includes billing documents for those services.
An example of how we use your medical information for treatment is that as a courtesy, we telephone our patients to confirm their appointments. It is used for payment, when you may submit a bill to your insurance company, or provide information to your managed care plan reviewer.
YOUR HEALTH INFORMATION RIGHTS
The health and billing records we maintain are the physical property of this office. The information in it belongs to you. You have the following rights:
• Request a restriction on certain disclosures of your health information (these requests may not always be granted, but will be carefully reviewed).
• Request a paper copy of the current Notice of Privacy Practices for Protected Health Information
• Request to inspect and copy your health record and billing record
• Appeal a denial of access to your protected health information, except in certain circumstances
• Request that your health care record be amended to correct incomplete or incorrect information. This request may be denied if the information was not created by us, was not part of the health information kept by the office, or is accurate and complete. However, if denied, you will be informed of the reason for the denial, and can submit a statement of disagreement to be kept with your record.
• Request that a communication of your health information be made by alternative means or at an alternative location
• Obtain an accounting of disclosures of health information (not including disclosures made at your request or authorization, or for treatment, payment, or operations)
• Revoke authorizations that you made previously to disclose information by writing my office, except to the extent that information or action had already been taken.
If you wish to exercise any of these rights, please contact Dr. Zwick.
Responsibilities of the Therapist
My office is required to maintain the privacy of your health information as required by law. This is why I am providing you with a Notice of duties and privacy practices regarding the information I collected and maintained about you. I will notify you if I cannot accommodate a requested restriction or request, and accommodate your reasonable requests regarding communicating health information.
Uses and Disclosures Not Requiring Authorization
As required by law, disclosure of abuse of a minor, disabled person, or of someone over age 60 is mandatory. Also, a patent’s relative, emergency room personnel, law enforcement or paramedical personnel may have to be contacted and given information in the event of an emergency (i.e. a threat
to health or safety). I may disclose to the Food and Drug Administration (FDA) heath information related to adverse events related to medications, nutritional supplements, or other products.
Disclosure Requiring Authorization
In Colorado, specific written authorization is required to disclose or release information regarding mental health treatment (except in an emergency), alcoholism or drug abuse treatment, or AIDS (Acquired Immune Deficiency Syndrome). The federal HIPAA laws allow disclosure of necessary information required for purposes of treatment, payment, and health care operations.
