NOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Responsibilities of KONTOS PSYCHOTHERAPY LCSW PC

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical developmental disability, mental health and/or substance abuse condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We do, however, reserve the right to change our privacy practices and the terms of this Notice, and to make the new Notice provisions effective for all PHI we maintain. Any changes to this Notice will be posted in my office. Copies of any revised Notices will be available to you upon request

If at any time, you have questions or concerns about the information in this Notice or about our office’s privacy
policies, procedures and practices, you may contact our Privacy Official or Office Staff.

Use and Disclosure of Health Information About You

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization.The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required,we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

Disclosure of Your Health Information That Requires Your Authorization

We will not disclose your health information without your authorization except as allowed or required by state or federal law. For all other disclosures, we will ask you to sign a written authorization that allows us to share or request your health information. Before you sign an authorization, you will be fully informed of the exact information you are authorizing to be disclosed/requested and to/from whom the information will be disclosed/requested.

You may request that your authorization be cancelled by informing our Privacy Official that you do not want any additional health information about you exchanged with a particular person/agency. You will be asked to
sign and date the Authorization Revocation section of your original authorization; however, verbal authorization is acceptable. Your authorization will then be considered invalid at that point in time; however, any actions that were taken on the authorization prior to the time you cancelled your authorization are legal and binding.

If you are a minor who has consented to treatment for services regarding the prevention, diagnosis and treatment of certain illnesses including: venereal disease and other diseases that must be reported to the State; pregnancy; abuse of controlled substances or alcohol; or emotional disturbance, you have the right to authorize disclosure of your health information. Disclosure of health information to external client advocates will require authorization by you and your personal representative if one has been designated. “If you are a minor whose parent or guardian has consented to your treatment for substance abuse, both you and your parent or guardian must authorize disclosure of your health information.”

Your Rights Regarding your PHI

You have the following rights regarding PHI we create &maintain about you by this office. To exercise any of these rights, please submit your request in writing to our Privacy Officer at PO Box 872 Lindenhurst NY 11757.

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies or electronic media. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another professional or individual. Your request must be in writing and forwarded to our Privacy Officer. You can expect a response to your request within 30 days.

Instead of providing you with a full copy of your health information record, we may give you a summary or explanation of your health information if you agree in advance to that format and to the cost of preparing such information.

  • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may submit a request in writing to our agency Privacy Official and explain your reasons for the amendment. We must respond to your request within 30 days of receiving your request. If we accept your request to change your health information, we will add your amendment but will not destroy the original record. In addition, we will make reasonable efforts to inform others of the changes, including persons you name who have received your health information and who need the changes.

We may deny your request if: (i) The information was not created by this office; (ii) The information is not part of the records used to make decisions about you; (iii) We believe the information is correct and complete; or (iv) Your request for access to the information is denied. If we deny your request to change your health information, we will explain to you in writing the reasons for denial and describe your rights to give us a written statement disagreeing with the denial. If you provide a written statement of disagreement, the statement will become a permanent part of your record. Whenever disclosures are made of the information in question, your written statement will be disclosed as well. Please contact the Privacy Officer if you have any questions.

  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction. However, if we do agree, we must follow the agreed upon restriction (unless the information is necessary for emergency treatment or unless it is a disclosure to the U.S. Secretary of the Department of Health and Human Services). You may cancel the restrictions at any time and we will ask that your request be in writing. In addition, this agency may cancel a restriction at any time, as long as we notify you of the cancellation.
  • Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters at a different location or by a different method. We will accommodate reasonable requests. We will agree with your request as long as it is reasonable to do so; however, your request must be made in writing and forwarded to Privacy Officer
  • Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
  • Right to a Copy of this Notice. You have the right to a copy of this notice.

Records of patients treated for alcohol or drug treatment are protected by Federal Confidentiality Rules (42CF part 2)

Violations/Complaints

If you believe we have violated your privacy rights, or if you want to file a complaint regarding our privacy practices, you may contact our Privacy Official. Contact information is as follows:

KONTOS PSYCHOTHERAPY LCSW PC

Attention: Privacy Officer

PO Box 872

Lindenhurst NY 11757-0872

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact Privacy Official for information

If you file a complaint, we will not take any action against you or change the quality of health care services we provide to you in any way.