NOTICE OF PRIVACY PRACTICES
Montesinos Counseling Services, LLC, 4720 Salisbury Road, Suite 242, Jacksonville, FL 32256
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to safeguarding your protected health information (PHI). PHI constitutes the information I maintain in records of the care and services you receive from me that can identify you. This includes information about your past, present, or future health or condition, the provision of health care services to you, and the payment for such health care. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by my mental health care practice. This notice will tell you how I may use and disclose your health information. I also describe your rights to the health information I keep about you and my obligations regarding using and disclosing your health information. I am required by law to:
Ensure health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices concerning health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, which will apply to all information I have about you. The new Notice will be available upon request in my office, on my website, and on the client portal.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories. Generally, the use of PHI means when I share, apply, utilize, examine, or analyze information within my practice. The disclosure of PHI means when I release, transfer, give, or otherwise reveal it to a third party outside my practice.
Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent
Federal privacy rules (regulations) allow healthcare providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization to carry out the healthcare provider’s treatment, payment, or healthcare operations.
For Treatment: I can use your PHI within my practice to provide you with mental health treatment. This includes consultation with clinical supervisors or other treatment team members. I may disclose your PHI to physicians, psychiatrists, psychologists, and licensed healthcare providers who provide you with healthcare services or are otherwise involved in your care. However, I prefer to have your authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between providers, and patient referrals for health care from one health care provider to another.
To obtain payment for treatment: I may use and disclose your PHI to bill and collect payment for the treatment and services I provided. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others who process health care claims for my office.
For health care operations: I may disclose your PHI to facilitate my practice's efficient and correct operation. For example, to maintain quality control, I might use your PHI to evaluate the quality of health care services you have received. Other examples of healthcare operations are business-related matters such as audits, administrative tasks and services, and disclosing PHI to my attorney or other consultants to ensure I comply with applicable laws.
Other disclosures: Your consent isn’t required if you need emergency treatment, provided I attempt to get your consent after treatment is rendered. If I try to get your consent, but you cannot communicate with me (for example, if you are unconscious or in severe pain), but I think that you would consent to such treatment if you could, I may disclose your PHI.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501. Any use or disclosure of such notes or records requires your authorization unless the use or disclosure is: a) For my use in treating you. b) For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c) For my use in defending myself in legal proceedings instituted by you. d) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e) Required by law, and the use or disclosure is limited to the requirements of such law. f) Required by law for certain health oversight activities about the originator of the psychotherapy notes. g) Required by a coroner who is performing duties authorized by law, and h) Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I WILL NOT use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I WILL NOT sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your authorization for the following reasons:
When disclosure is required by state or federal law, the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse or preventing or reducing a serious threat to anyone’s health or safety.
For efforts to address risks of danger to self or others, including if you are experiencing a mental or emotional condition causing you to pose a serious risk of danger to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. All research projects are subject to a special review process and the confidentiality requirements of state and federal law.
Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although I prefer obtaining Authorization from you, I may provide your PHI to comply with workers' compensation laws.
Disclosures to Business Associates: I may disclose PHI about you to business associates for services that they may provide to or for me to assist me in providing quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.
Appointment reminders and health-related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or another person you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergencies.
VI. YOU HAVE THE FOLLOWING RIGHTS CONCERNING YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, by home or office phone or by an alternate method such as via e-mail instead of by regular mail) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information I have about you. I will provide you with a copy of your record or a summary of it (if you agree to receive a summary) within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or healthcare operations or for which you provided me with Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy.
VII. COMPLAINTS.
If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VIII below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you.
VIII. CONTACT INFORMATION FOR QUESTIONS ABOUT THIS NOTICE TO ISSUE A COMPLAINT ABOUT THESE PRIVACY PRACTICES.
If you have any questions about this notice or any complaints about these privacy practices or would like to know how to file a complaint with the Secretary of the DHHS, don't hesitate to get in touch with Steven Montesinos, LMHC, Privacy Officer, Owner, Montesinos Counseling Services, LLC, 4720 Salisbury Road, Suite 242, Jacksonville, FL 32256 Phone: 904-701-4662, steven@montesinoscounseling.com
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on May 6, 2018