This notice describes how FairView Counseling may use your medical information and how you can access this information. Please review it carefully.
About this notice
This notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your health information. Protected health information (PHI) is information about you including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required by law to maintain the privacy of your PHI, give you this notice of our legal duties and privacy practices with respect to your PHI, and follow the terms of our notice that are currently in effect. We may change the terms of our notice at any time. The new notice will be effective for all PHI that we maintain at the time as well as any information we receive in the future. You can obtain any revised Notice of Privacy Practices by contacting our office.
How we may use and disclose your protected health information
The following information describes how we may use and disclose your health information. It contains some examples, but this should not be considered an exhaustive list, and some examples may not apply to your situation.
Treatment: We will use your health information to provide treatment and services to you. The health information obtained about you by our staff will be recorded in your health record and will be used to determine the best course of treatment for you. If medically necessary, we may write a prescription for you. Also, any staff involved in your care will share information about you with each other, but only to the minimum extent necessary.
Payment: We will use and disclose your health information to prepare, submit and/or process bills to you or your insurer. We may contact your insurer to determine your eligibility for services, and we may provide your insurer with information regarding your treatment and the services that we provide to you. The information we use on a bill may include information that identifies you, as well as your diagnosis, services performed and/or supplies and equipment furnished to you.
Health Care Operations: We will use and disclose your health information in the course of our day-today operations. Certain members of our staff may use your health information to assess the quality of the services that we provide to you, and to conduct normal business planning activities.
Contacting You: We may use your health information to contact you in order to: 1) Remind you of a scheduled appointment, 2) Reschedule an existing appointment, 3) Talk to you about a missed appointment, 4) Inform you about potential treatment alternatives or other health-related information, 5) Talk to you about an outstanding balance owed to us, and 6) Advise regarding issues related to the services that we provide to you or the seeking payment for those services.
Family, Relatives, and Others: Upon obtaining your written authorization, we may disclose your health information to family, relatives, your primary care physician, and other persons identified by you, but only the health information which is directly relevant to their involvement, care, and/or payment activities pertaining to you.
Notification in Case of Emergency: Our staff, using its best judgment, may use or disclose health information about you to notify or assist in notifying a family member, personal representative, or another person/entity/health care provider in the case of an emergency.
Deceased Individuals: We may disclose health information that is consistent with applicable law to funeral directors, medical examiners, coroners, executors of your estate, and others as allowed by law so that they may carry out their duties. Marketing: We may use your health information for “marketing” purposes, but only after obtaining your written authorization to use your health information.
Court Orders: We may disclose your health information pursuant to a court order issued by a court of competent jurisdiction.
Suspected Abuse, Neglect, or Domestic Violence: We may disclose your health information, as required or allowed by law, if we suspect abuse, neglect, or domestic violence, but only to entities authorized to receive such reports.
Licensing and Accreditation Organizations: We may disclose your health information pursuant to licensing and accreditation activities to maintain the health, safety and welfare of the people we serve and/or to promote quality outcomes.
Correctional Institution: Should you become an inmate of a correctional institution or be placed under supervision of the juvenile or adult criminal court, we may disclose to the institution or agents thereof, probation or parole officer or their designees, health information necessary to preserve or maintain your health and the health and safety of other individuals.
Law Enforcement: We may disclose your health information for certain law enforcement purposes, as required or allowed by law.
Health Oversight and Public Health Activities: We may disclose your health information to appropriate health oversight agencies, and for the purposes of preventing or controlling disease, injury, or disability, as required or allowed by law.
To Avert a Serious Threat to Health or Safety: We may disclose your health information, with certain exceptions, in order to avert a serious threat to the health or safety of you or others.
Disclosures Required by Law: We may disclose your health information in other circumstances, as required by regulation or law.
Your Privacy Rights Pertaining to Your Health Information
Although your health record remains the physical property of our organization, the information contained in our records belongs to you. You have numerous rights regarding your health information.
Written Authorization for Disclosure of Health Information: When required by regulation, law, or our internal privacy practices, we will obtain your written permission prior to disclosing your health information to persons/entities outside of our organization. This permission will be obtained using an Authorization to Release / Request Information form. You have the right to refuse to sign any Authorization, and the right to revoke a previously signed Authorization. Please make sure that you carefully read the Authorization form prior to signing it.
Confidential Communications: You have the right to request that we contact you at a certain location, or in a certain manner. As an example, you may request that we use an alternate address or phone number to contact you. We will attempt to accommodate reasonable requests, but we are not required to do so.
Requesting Restrictions to Our Uses and Disclosures: You may request that we use or disclose your health information in a certain way related to our treatment, payment, and health care operations activities. As an example, you may request that we not disclose your health information to a particular person. Please be aware that we are not required to agree to a requested restriction, but if we do agree to a request we are bound by our agreement except in emergency circumstances and certain other situations. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.
Access to Your Health Records, and Obtaining Copies: You may request to review and obtain a copy of certain of your health records. We may deny your request under limited circumstances, however, you may request a review of certain denials. If you request and are granted a copy of your health records, we may charge you a reasonable cost-based fee. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.
Amendment of Your Health Records: You may request an amendment to certain aspects of your health information if you believe it is incorrect or incomplete. We may deny you request under certain circumstances. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.
Disclosure Accounting: You may request an accounting of certain disclosures that we have made regarding your health information. The first accounting requested within a 12-month period will be provided at no charge. We may charge a reasonable cost-based fee for all additional requests received within that same 12-month period. We have developed a form for this request. Please speak to the front office or your therapist about this right.
Receiving a Copy of This Notice: You are entitled to receive a copy of this Notice at any time. To obtain a copy, speak to one of our staff. Additionally, if we maintain a website, we will make this Notice available on the website.
Filing a Complaint: You may file a complaint with us, or with the Federal Government, if you believe that your privacy rights have been violated. Review the section below entitled “Requesting Assistance, Asking Questions, and Filing Complaints” to file a complaint.
Our Duties and Responsibilities
We will not use or disclose your health information without your consent and/or authorization, except as allowed by law and as described in this Notice. We are required by law to maintain the privacy of your health information, and to provide you with a Notice as to our legal duties, and our privacy practices, with respect to the information we collect and maintain about you. We are required to abide by the terms of this Notice, to notify you in writing if we are unable to agree to a requested restriction on the use of your health information, and to accommodate reasonable requests made by you to communicate health information by alternative means or to alternative locations. We reserve the right to change our privacy practices at any time, and to make the new provisions effective for all protected health information that we maintain.
Requesting Assistance, Asking Questions, and Filing Complaints
If you have questions, would like additional information about our privacy practices, or experience a problem, you may contact our Managing Director at 610-396-9091. If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer, or with the Secretary of Health and Human Services, U.S. Department of Health and Human Service, 200 Independence Avenue S.W., Washington, D.C. 20201. You may also contact the United States Office of Civil Rights. There will never be any type of retaliation for making an inquiry or for filing a complaint, and you will never be asked to waive your right to make a complaint or report a problem as a condition of receiving services from us.