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Notice of Privacy Practices (Effective 4-14-03)

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO IT. PLEASE REVIEW IT CAREFULLY.

We at Therapy Works respect our legal obligation to keep your health information private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reasons why we use or disclose your health information are for treatment, payment, or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you, testing, referring you to another professional, or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health insurance or other sources of payment, preparing and sending bills or claims, and collecting unpaid amounts (either ourselves or through a collection agency or an attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits, internal quality assurance, personnel decisions, participation in managed care plans, and defense of legal matters.

We routinely use your health information inside our office for these purposes without any special permission. Disclosure of your health information outside of our office requires your written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such disclosures include:

• When a state or federal law mandates that certain health information be reported for a specific purpose;
• Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
• Uses and disclosures for health oversight activities, such as licensing of therapists; for audits by Medicare and Medicaid; or for investigation of possible violations of health care laws;
• Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
• Disclosures for law enforcement purposes;
• Uses or disclosures for research;
• Uses and disclosures to prevent a serious threat to health or safety;
• Disclosures of de-identified information;
• Disclosures relating to worker's compensation programs;
• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• Disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information.

MISSED OR CHANGED APPOINTMENTS

We may call or write to advise you of a missed or changed appointment. Unless you advise us otherwise, written notification may be sent to your home address. If we attempt to telephone you, it will be at whatever cell, home or work telephone numbers that you provided us. A brief message will be left with whoever answers your home or cell telephone or with whatever answering device or service that you have.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The form's content is determined by federal law. We may initiate the authorization process if the use or disclosure is our idea. You may initiate the process if it is your idea.

If we initiate the process and ask you to sign an authorization, you do not have to sign it. If you don't sign it, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing and should be sent directly to your therapist at the address or fax shown at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

• You can ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we do agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to your therapist at the address or fax shown at the beginning of this Notice.
• You can ask us to restrict our confidential communications with you. For example, you may request that we contact you at home instead of work, or vice versa. We will attempt to honor these requests as long as they are reasonable and if you pay us for any extra cost. To ask for a restriction, send a written request to your therapist at the address or fax shown at the beginning of this Notice.
• You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation. If you want to review or get photocopies of your health information, send a written request to your therapist at the address or fax shown at the beginning of this Notice.
• You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend it. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to your therapist at the address or fax shown at the beginning of this Notice.
• You can get a list of disclosures that we have made of your health information with the past six years (or a shorter period if you want). By law, the list will not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law, and some other limited disclosures. If you want a list, send a written request to your therapist at the address or fax shown at the beginning of this Notice.
• You can have additional paper copies of this Notice of Privacy Practices upon request. If you want additional paper copies, send a written request to your therapist at the address or fax shown at the beginning of this Notice, or you may pick up extra copies at our office.

OUR NOTICE OF PRIVACY PRACTICE

By law, we must abide by the terms of this Notice of Privacy Practices. We reserve the right to change this notice at any time. If we change this Notice, the new privacy practices will apply to existing health information as well as such information that we may generate in the future. If we change our Notice, we will post the new Notice in our office and on our web site, and will have paper copies available in our office.

COMPLAINTS

If you think that we have not respected the privacy of your health information, you may complain to us directly or to the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue, Washington, D.C., 20201. We will not retaliate against you if you make a complaint. If you want to complain to us directly, you may send a written complaint to your therapist at the address or fax shown at the beginning of this Notice. If you prefer, you may discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, feel free to call or visit our office at the address or phone number shown at the beginning of this Notice.