HIPAA Compliance Statement
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BEFORE SIGNING.
Understanding Your Health Information
When you begin working with Inclusive Mind Wellness a record of treatment is made. Typically, this record contains your history, assessment, medical information, diagnoses, treatment, a plan for future treatment, etc. This information often referred to as you/your child’s clinical record, serves as:
- Basis for planning your care and treatment.
- Legal document describing the care you received.
- Means by which you or a third party payer can verify that services billed were provided
- A source of data for health officials charged with improving the health of the nation, or needed services for the area.
- A tool by which future or continual services can be approved.
- Understanding what is in this record will help you to ensure its accuracy, better understand who, what, when and why others may access you information and help to make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of Inclusive Mind Wellness the information belongs to you. You have the following rights:
A. Right to Request a Restriction
You have the right to request a restriction on our use and sharing of your protected health information. Inclusive Mind Wellness can deny the request if it is unreasonable or would be detrimental to your treatment.
B. Right to a Paper Copy of this Notice
You have a right to obtain a paper copy of this notice.
C. Right to Amend Your Health Information
You have the right to request an amendment to the health information we maintain about you if you feel it is incorrect or incomplete for as long as the information is kept by Inclusive Mind Wellness. To request an amendment, you must submit a request in writing and state the reason that supports your request. The disputed information will remain in the record along with the amended information.
Health Care Insurance Providers
We do not file your insurance claims at this time, you may obtain a superbill through the patient portal that you may submit to your insurance carrier. In order to assist you with obtaining reimbursement for our services, your insurance carrier may require that we provide a clinical diagnosis, or additional clinical information such as treatment plans or summaries, or copies of your or your child’s entire clinical record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. We will provide you with a copy of any report or form that we submit upon your request. By signing this Notice, you agree that we can provide requested information to your carrier for authorization of services and if/when you choose to file a claim for any services that we have provided to you or your child.
Confidentiality, Records, and Release of Information
Psychiatric services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by law and our professional codes of conduct/ethics. These exceptions are discussed below.
Others We May Share Your Information With
As required by law we will disclose you/your child’s protected health information, even if you do not sign an authorization form, under the following circumstances:
- Individuals at Inclusive Mind Wellness when and to the extent necessary to facilitate the delivery of professional services to you.
- Certain individuals on an emergency basis to if the clinician believes that such disclosure is necessary to initiate or seek emergency hospitalization of the client.
- Disaster Relief-to an agency organizing disaster relief efforts.
- Public Health Activities-such as: reporting to a public health or government authority for preventing or controlling disease, injury, or reporting child abuse or neglect.
- Food and Drug Administration (FDA)-concerning adverse events or problems with products or medications for tracking purposes to enable product recalls or to comply with other FDA requirements.
- To notify a person who may have been exposed to a communicable disease or may otherwise be at-risk of contracting or spreading a disease or condition
- For certain purposes involving workplace illnesses or injuries.
- Reporting victims of abuse, neglect or domestic violence-information will be disclosed as required by law.
- Judicial and Administrative proceedings-information may be disclosed in response to a court or administrative order, subpoena, discovery requests, or other lawful process. Efforts will be made to notify you about the request or to obtain an order or agreement protecting the information.
- Health oversight activities-information may be disclosed to a health oversight agency for activities authorized by law, such as, audits, inspections, investigations, licensure actions or other legal proceedings.
- Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations.
- To avert a serious threat to health or safety-any disclosure would be made only to someone able to prevent the threat of safety to you/your child, the public or another person.
- Research-only under your specific disclosure.
- Workers Compensation.
- Law Enforcement-as required by law to comply with reporting requirements including, but not limited to: complying with court orders, warrants, subpoenas, summons, identifying or locating a fugitive, missing person or material witness, when information is requested about the victim of a crime if the individual agrees, to report information about a suspicious death, to provide information about criminal conduct occurring at the agency, or information about emergency circumstances about a crime.
- National Security and Intelligence Activities, Protective Services for the President and others.
Legal Proceedings
If you are involved in a court proceeding and a request is made for information concerning our professional services, we cannot provide any information without your written authorization or a court order. However, a court order may force us to reveal information. In that case, we will reveal only the minimally acceptable amount of information. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. Also, if a client files a complaint or lawsuit against anyone affiliated with Inclusive Mind Wellness, we may disclose any and all relevant information regarding that client we deem necessary in order to defend ourselves.
To Protect the Client or Others from Harm
If we have reason to suspect that a minor, elderly, or person with a disability is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include but not limited to, notifying the police or an intended victim, a minor’s parents, or others who could provide protection, or seek appropriate hospitalization.
Your Authorization is Required for Other Uses of Protected Health Information
Inclusive Mind Wellness will use and disclose protected health information (other than described in this Notice or required by law) only with your written authorization. You may revoke your authorization to use or disclose protected health information in writing, at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization except where we have already relied on the authorization.
Our Responsibility Regarding You/Your Child’s Protected Health Information
Inclusive Mind Wellness is required by law to:
- Maintain the privacy of your health information.
- Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
- Abide by the terms of this notice.
- Notify you if we are unable to agree to a requested restriction.
- Inform you promptly if a breach occurs that may have compromised the privacy or security of your information.
We reserve the right to make changes to this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. Any changes made will affect the protected health information we maintain at that time. We will provide a revised copy of the notice to patients or parents/legal guardians upon request on or after the effective date of revision.
WE WILL NOT USE OR DISCLOSE YOU/YOUR CHILD’S PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION, EXCEPT AS DESCRIBED IN THIS NOTICE.
If you have any questions regarding this Notice or wish to receive additional information about our privacy practices, please contact our office. If you believe your privacy rights have been violated, you may file a complaint at our service location either in person or by mail.
CONSENT
All information is private and not shared with any outside parties. Agreement of Informed Consent and the HIPAA Privacy Policy described above and the information below must be completed before any services can be provided.
Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms, and that you have received the above-mentioned HIPAA notice form described above.