Effective: July 1, 2015
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.
Your Rights
You have the right to:
Get a copy You can ask to see or get an electronic or paper copy of your mental health of your paper or electronic medical record
record and other health information we have about you.
• 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. Correct your mental health record.
• You can ask us to correct health information about you that you think is incorrect or incomplete.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communication.
• 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 the information we share.
• You can ask us not to use or share certain health information for treatment, payment, or other 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 insurance. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared your 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 agreedto 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 believe your privacy rights have been 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 forCivil 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.
Our Uses and Disclosures
We may use and share your information to:
• Treat you. We can use your health information and share it with other professionals who are treating you.
• Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary.
• Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities.
• Use of a collection agency for fees may require disclosure of your demographic information as well as dates and times of services rendered.
• 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
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 orfederal laws require it, including Department of Health and Human Services if they want to see that we’re complying with federal privacy law.
• We can share health information with a coroner, medical examiner, or funeral director when an individual die.
• We can use or share health information about you: For workers’ compensation claims
• We can share health information for lawsuits and legal actions. We can share information about you in response to a court or administrative order or in response to a subpoena. We can share for law enforcement purposes or with a law enforcement official or with health oversight agencies for activities authorized by law.
• For special government functions such as military, national security, and presidential protective services
Exceptions to confidentiality, can be found in C.R.S. §12-245-220.
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 give you 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.
• We DO NOT SHARE your personal information with third parties for marketing/promotional purposes
For more information see this website:
www.hhs.gov/ocr/privacy
Other Pertinent Information Regarding Privacy:
ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email, website, or text messaging for issues regarding scheduling or cancellations, we can do so but we can’t
ensure confidentiality. If you use these methods to communicate with your counselor,
there is a reasonable chance that a third party may be able to gain access to those
messages. The types of parties that may intercept these messages include, but are not
limited to:
-Those who have access to your phone, computer, or other devices that you use to read
and write messages.
-Your employer, if you use your work email to communicate with us
-Internet server administrators and others who monitor Internet traffic
While we may try to return messages in a timely manner, we cannot guarantee
immediate response and request that you do not use these methods of communication
to discuss personal therapeutic content and/or request assistance for emergencies. We
do not accept friend or contact requests from current or former clients on any social
networking site
In case of EMERGENCIES: We may not be able to respond to crisis situations outside of sessions. If you are in an immediate crisis, please call 911 or proceed to the nearest emergency room. If you are experiencing thoughts of suicide, please call 911 or proceed to the nearest emergency room. Helpful Resources
-988 national mental health hotline
-Tessa’s 24-hour crisis line (domestic violence & sexual assault) – 719-633-3819
-National 24-hour Suicide Prevention Lifeline – 1-800-273-8255
-Diversus Health 24/7 Walk-in Crisis Center – 115 S Parkside Drive Colorado
Springs, Co 80910, 719-572-6100
-1-800-SUICIDE
-1-800-656-HOPE
-1-800-TLC-TEEN
-844-493-TALK
-Text TALK to 38255 CO Crisis Support Line
-741-741 free 24/7 crisis text line for suicidal thoughts, bullying, depression & other tough issues.
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.
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