Notice of Privacy Practices

Mend Center for Psychotherapy, LLC

Scott Koeneman, Psy.D.

NOTICE OF PRIVACY PRACTICES 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.

This notice takes effect on September 23, 2013 and remains in effect until we replace it.

The privacy of your mental health information is important to us. We understand that your mental health information is personal and we are committed to protecting it. We create a record of the care and services you receive. We need to this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share mental health information about you. We also describe your rights and certain duties we have regarding the use and the disclosure of mental health information.

We are required by law to:

1. Keep your mental health information private.

2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your mental health information.

3. Follow the terms of the current notice.

We have the right to:

1. Change our privacy practices and the terms of this notice at any time provided that changes are permitted by law.

2. Make the changes in our privacy practices and the new terms of our notice effective for all mental health information that we keep, including information previously created or received before the changes.

Notice of changes to privacy practices:

1. Before we make an important change in our privacy practices we will change this notice and make the new notice available upon request.

WE WILL OBTAIN AN AUTHORIZATION FROM YOU BEFORE USING OR DISCLOSING:

1. Private Health Information (PHI) in a way that is not described in this Notice.

2. Psychotherapy notes.

3. Private Health Information for marketing purposes.

4. Private Health Information in a way that is considered a sale of PHI.

USE AND DISCLOSURE OF YOUR MENTAL HEALTH INFORMATION

The following section describes different ways that we use and disclose mental health information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose mental health information. We will not use or disclose your mental health information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by providing us with your revocation in writing.

FOR TREATMENT: We may use mental health information about you to provide you with treatment or services. We may disclose mental health information about you to your treatment team or other people who are taking care of you. We may also share mental health information about you to your other health care providers to assist them in treating you.

FOR PAYMENT: We may use and disclose your mental health information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your mental health information.

FOR HEALTH CARE OPERATIONS: We may use and disclose your mental health information to your health care service plan or insurance company for purposes of administering the plan, such as case management and care coordination.

APPOINTMENT REMINDERS OR CHANGES IN APPOINTMENTS: We may use or disclose your mental health information to contact you as a reminder that you have an appointment. We may also contact you to notify you of a change in your appointment. For example, if your therapist were ill, we may contact you to notify you that the appointment is canceled.

WHEN DISCLOSURE IS REQUIRED BY STATE, FEDERAL, OR LOCAL LAW: We may use or disclose your mental health information when a law requires that we report information about the suspected child, elder, or dependent adult abuse or neglect, or in response to a court order. We also disclose information to authorities that monitor compliance with these privacy requirements.

TO AVOID HARM: We may use or disclose information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your mental health information if it is necessary to prevent a serious threat to your health or the safety of others.

JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may disclose your mental health information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

LAW ENFORCEMENT OFFICIALS: We may disclose your mental health information to the police or other law enforcement officials as required by law or in compliance with a court order or grand jury or administrative subpoena.

FOR HEALTH OVERSIGHT ACTIVITIES: We may disclose your mental health information to a health oversight agency for activities authorized by the law.

SPECIALIZED GOVERNMENT FUNCTIONS: We may disclose your mental health information to units of the government with special functions, such as the US military or the US Department of State under certain circumstances.

DISCLOSURE TO RELATIVES, CLOSE FRIENDS, AND OTHER CARE GIVERS: We may use or disclose your mental health information to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree to object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interest. If we disclose information to a family member, other relative, or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care.

WORKERS COMPENSATION: We may disclose mental health information when authorized or necessary to comply with law relation to workers compensation or other similar programs.

AS REQUIRED BY LAW: We may use and disclose your mental health information when required to do so by any other law not already referred to in the preceding categories.

WHEN THE USE AND DISCLOSURE WITHOUT YOUR CONSENT OF AUTHORIZATION IS ALLOWED UNDER OTHER SECTIONS OF SECTION 164.512 OF THE PRIVACY RULE AND THE STATE’S CONFIDENTIALITY LAW:

The includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

YOUR INDIVIDUAL RIGHTS REGARDING YOUR MENTAL HEALTH INFORMATION:

You have the following rights regarding mental health information we maintain about you:

1. You have the right to inspect and copy your mental health information. You may request that we provide copies in a format other than photocopies. We will use the format your request unless it is not practical for us to do so. You must make your request in writing. We will respond to your written request to inspect records. A charge for copying, mailing, and related expenses will apply.

2. Receive a list of all the times we or our business associates shared your mental health information for purposes other than treatment, payment, and health care operation, and other specified exceptions.

3. Request that we place additional restrictions on our use or disclosure of your mental health information. We are required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).

4. Request that we communicate with you about your mental health information by different means or to different locations. Your request that we communicate your mental health information to you by different means or at different locations must be made in writing.

5. Request that we change certain parts of your mental health information. We may deny your request if we did not create the information you want to be changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information that you want to be changed. If we accept your request to change information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.

6. If you have received this notice electronically and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing at any times.

7. Have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

8. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI: (b) that PHI has not been encrypted to government standards: and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for mental health information we already have about you as well as any information we receive in the future.

QUESTIONS AND COMPLAINTS

If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. All complaints must be submitted in writing. You may also submit a written complaint to the US Department of Health and Human Services. You will not be penalized for filing a complaint.