TINA HARP, COUNSELOR, INC.
3610 S. Western Ave., Suite 2 Sioux Falls, SD 57105
NOTICE OF PRIVACY PRACTICES
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.
This notice takes effect on 9/23/2013 and remains in effect until TINA HARP, COUNSELOR, INC. (TINA HARP, COUNSELOR, INC.) replaces it. The privacy of your medical information is important to TINA HARP, COUNSELOR, INC. understands that your medical information is personal and is committed to protecting it. TINA HARP, COUNSELOR, INC. creates a record of the care and services you receive at this organization. TINA HARP, COUNSELOR, INC. needs this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways TINA HARP, COUNSELOR, INC. may use and share medical information about you. TINA HARP, COUNSELOR, INC. also describes your rights and certain duties it has regarding the use and disclosure of medical information.
Obligations and Activities of TINA HARP, COUNSELOR, INC. : Covered Entity. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean [Tina Harp, Counselor, Inc.].
(a) Not use or disclose protected health information other than as permitted or required by the Agreement or as required by law;
(b) Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the Agreement;
(c) Report to covered entity any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware;
(d) In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the business associate agree to the same restrictions, conditions, and requirements that apply to the business associate with respect to such information;
(e) Make available protected health information in a designated record set to the “covered entity” as necessary to satisfy covered entity’s obligations under 45 CFR 164.524;
(f) Make any amendment(s) to protected health information in a designated record set as directed or agreed to by the covered entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy covered entity’s obligations under 45 CFR 164.526;
(g) Maintain and make available the information required to provide an accounting of disclosures to either the “covered entity” or “individual” as necessary to satisfy covered entity’s obligations under 45 CFR 164.528;
(h) To the extent the business associate is to carry out one or more of covered entity's obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to the covered entity in the performance of such obligation(s); and
(i) Make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules.
Permitted Uses and Disclosures by Covered Entity:
(a) Business associate may only use or disclose protected health information
(b) Business associate may use or disclose protected health information as required by law.
(c) Business associate agrees to make uses and disclosures and requests for protected health information
(d) Business associate may disclose protected health information for the proper management and administration of business associate or to carry out the legal responsibilities of the business associate, provided the disclosures are required by law, or business associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies business associate of any instances of which it is aware in which the confidentiality of the information has been breached.
Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions:
(a) Covered entity shall notify business associate of any limitation(s) in the notice of privacy practices of covered entity under 45 CFR 164.520, to the extent that such limitation may affect business associate’s use or disclosure of protected health information.
Term and Termination
(a) Term. The Term of this Agreement shall be effective as of [Insert effective date], and shall terminate on [Insert termination date or event] or on the date covered entity terminates for cause as authorized in paragraph (b) of this Section, whichever is sooner.
(b) Termination for Cause. Business associate authorizes termination of this Agreement by covered entity, if covered entity determines business associate has violated a material term of the Agreement [and business associate has not cured the breach or ended the violation within the time specified by covered entity].
Law Requires TINA HARP, COUNSELOR, INC. to:
1. Keep your medical information private.
2. Give you this notice describing the legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the current notice.
TINA HARP, COUNSELOR, INC. Has the Right to:
1. Change the privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
2. Make the changes in the privacy practices and the new terms of our notice effective for all medical information that TINA HARP, COUNSELOR, INC. maintains, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before making an important change in our privacy practices, TINA HARP, COUNSELOR, INC. will change this notice and make the new notice available upon request.
The following section describes different ways that TINA HARP, COUNSELOR, INC. use and disclose medical information. Not every use or disclosure will be listed. However, TINA HARP, COUNSELOR, INC. has listed all of the different ways that are permitted to use and disclose medical information. TINA HARP, COUNSELOR, INC. will not use or disclose your medical 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 writing to us at the address provided at the end of this notice.
PSYCHOTHERAPY NOTES: Psychotherapy notes may be released in response to a complaint filed against the counselor. Please also refer to the “Informed Consent” form.
FOR TREATMENT: TINA HARP, COUNSELOR, INC. may use medical information about you to provide you with medical treatment or services. TINA HARP, COUNSELOR, INC. may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. TINA HARP, COUNSELOR, INC. may also share medical information about you to your other health care providers to assist them in treating you.
FOR PAYMENT: TINA HARP, COUNSELOR, INC. may use and disclose your medical 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 medical information. I understand that as a courtesy, TINA HARP, COUNSELOR, INC. contracted with an independent billing company, will process my insurance if information is provided. I understand that I am financially responsible to Tina Harp, DBA as Tina Harp, Counselor, Inc., for all charges including those not covered by my insurance, as well as penalties for failure to pre-certify. I understand that all accounts will be due upon receipt of a bill regardless of insurance claim status and a late payment fee of 1% monthly will be charged, beginning with the third statement. In instances of delinquent accounts, billing information will be provided to a third party for collection purposes. In the event that your account becomes more than 90 days past due and you have not followed through on a payment plan, your account will be sent to collections. I understand as the client that I will be responsible for any collection fees that are charged in order to collect the debt I owe. This will only take place after a final notice has been issued by Phillips Mental Health Services and no response has been received within the allowed time frame from the client.
I have been informed of fees and authorize insurance or other payment directly to Tina Harp of TINA HARP, COUNSELOR, INC. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your insurance plan. Please check your benefits!
FOR HEALTH CARE OPERATIONS: TINA HARP, COUNSELOR, INC. may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health care operations, TINA HARP, COUNSELOR, INC. may use and disclose medical information for the following purposes.
Facility Directory: Unless you notify us that you object, the following medical information about you will be placed in our facility directories: your name; your location in our facility; your condition described in general terms; your religious affiliation, if any. TINA HARP, COUNSELOR, INC. may disclose this information to members of the clergy or, except for your religious affiliation, to others who contact us and ask for information about you by name.
Notification: TINA HARP, COUNSELOR, INC. may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. TINA HARP, COUNSELOR, INC. will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. TINA HARP, COUNSELOR, INC. will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.
Disaster Relief: TINA HARP, COUNSELOR, INC. may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.
Research in Limited Circumstances: TINA HARP, COUNSELOR, INC. may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.
Funeral Director, Coroner, and/or Medical Examiner: To help them carry out their duties, TINA HARP, COUNSELOR, INC. may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
Specialized Government Functions: Subject to certain requirements, TINA HARP, COUNSELOR, INC. may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: TINA HARP, COUNSELOR, INC. may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, TINA HARP, COUNSELOR, INC. may share your medical information with law enforcement officials. TINA HARP, COUNSELOR, INC. may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. TINA HARP, COUNSELOR, INC. may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, TINA HARP, COUNSELOR, INC. may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. TINA HARP, COUNSELOR, INC. may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. TINA HARP, COUNSELOR, INC. may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: TINA HARP, COUNSELOR, INC. may use and disclose medical 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. TINA HARP, COUNSELOR, INC. may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. TINA HARP, COUNSELOR, INC. may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: TINA HARP, COUNSELOR, INC. may disclose health information when authorized or necessary to comply with laws relating to workers compensation or other similar programs.
Health Oversight Activities: TINA HARP, COUNSELOR, INC. may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, TINA HARP, COUNSELOR, INC. may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
Appointment Reminders: TINA HARP, COUNSELOR, INC. may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.
Alternative and Additional Medical Services: TINA HARP, COUNSELOR, INC. may use and disclose medical information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
You Have a Right to:
1. Look at or get copies of certain parts of your medical information. You may request that TINA HARP, COUNSELOR, INC. provide copies in a format other than photocopies. TINA HARP, COUNSELOR, INC. will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, TINA HARP, COUNSELOR, INC. will charge you $ for each page, and postage if you want the copies mailed to you. Contact TINA HARP, COUNSELOR, INC. using the information listed at the end of this notice for a full explanation of our fee structure.
2. Receive a list of all the times TINA HARP, COUNSELOR, INC. shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
3. Request that TINA HARP, COUNSELOR, INC. place additional restrictions on the use or disclosure of your medical information. TINA HARP, COUNSELOR, INC. is not required to agree to these additional restrictions, but if TINA HARP, COUNSELOR, INC. does, TINA HARP, COUNSELOR, INC. will abide by our agreement (except in the case of an emergency).
4. Request that TINA HARP, COUNSELOR, INC. communicate with you about your medical information by different means or to different locations. Your request that TINA HARP, COUNSELOR, INC. may communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
5. Request that TINA HARP, COUNSELOR, INC. change certain parts of your medical information. TINA HARP, COUNSELOR, INC. may deny your request if TINA HARP, COUNSELOR, INC. does not create the information you want changed or for certain other reasons. If TINA HARP, COUNSELOR, INC. denies your request, TINA HARP, COUNSELOR, INC. will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If TINA HARP, COUNSELOR, INC. accepts your request to change the information, TINA HARP, COUNSELOR, INC. 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 to the contact person listed at the end of this notice.
If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact Tina Harp, TINA HARP, COUNSELOR, INC. at (605)274-1944. You may also contact the secretary of the U.S. Department of Health and Human Services at the following address: U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201 or the South Dakota Board of Examiners for Counselors and Marriage & Family Therapists at: PO Box 2164, Sioux Falls, South Dakota 57101. Ph: (605)-331-2927