MILESTONES

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION

ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice is effective on April 1, 2008.

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) requires all health care records and other individually identifiable health information (PROTECTED HEALTH INFORMATION) used or disclosed to me in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the client, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information.

Use and disclosure of protected health information for the purposes of providing services: Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities.
• Health Care Operations include the business aspects of running my practice, such as, review of treatment procedures, review of business activities, certification, staff training, and compliance and licensing activities.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services. I will use and disclose your Protected Health Information when I am required to do so by federal, state or local law. I may disclose your Protected Health Information to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if I have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. I may release your Protected Health Information to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. I may use and disclose your Protected Health Information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, I will only make disclosures to a person or organization able to help prevent the threat.

I am required by law to protect the privacy of your Protected Health Information and to abide by the terms of the Notice of Privacy Practices. I will make and post revisions to the Notice of Privacy Practices in accordance with the law. You may obtain a written copy of these changes by written request. Further, a general summary of the HIPAA Privacy Rule may be obtained upon request also.

Your written authorization will be required for any other uses or disclosures. Should you choose to revoke your authorization, you may do so only in writing. I will abide by your written request with the exception of information I released upon obtaining the written authorization and releasing of information as required by law.

You may contact the Privacy Officer in writing to invoke your following rights:

• You may request in writing that I restrict using and disclosing your Protected Health Information

to family members and relatives, friends, or others you identify. I reserve the right to deny this

request.

• You may request an amendment to your Protected Health Information.
• You may request alternative means or locations in which you receive confidential

communications.

• You may request an accounting of disclosures of Protected Health Information beyond treatment,

payment, and health care operations.

• You may file a formal, written complain with me at the address below or with the Department of Health & Human Services, Office of Civil Rights, if you feel your privacy rights have been violated.

For more information regarding our Privacy Practices, please contact:

The Privacy Officer

Amy Sutton, MA

1720 Jet Stream Drive, Suite 203

Colorado Springs, CO 80921

(719) 494-5781

For more information about HIPAA or to file a complaint, please contact:

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

877-696-6775 (Toll free)

I have received a copy of Amy Sutton, MA’s Notice and am aware of these Privacy Practices.

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Client Signature (parent or guardian of minor) Date