HIPAA POLICY

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.

 

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health information.

 

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

 

Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination.

 

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

 

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

 

We may create and distribute de-identified health information by removing all references to individually identifiable information.

 

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

 

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

 

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

 

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

 

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

 

The right to inspect and copy your protected health information.      

 

The right to amend your protected health information.

 

The right to obtain a paper copy of this notice from us upon request.

 

This notice is effective as of February 1, 2019 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

 

You have recourse if you feel that your privacy protections have been violated. You have  the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the polices and procedures of our office. We will not retaliate against you for filing a complaint.

 

Please contact the following for more information:

 

The U.S. Department of Health & Human Services Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202) 619-0257

Toll Free: 1-877-696-677

 

 

Acknowledgement That You Have Received Our HIPAA Privacy Notice

 

We are required by law to keep your health information and records safe.

 

This information may include:

 

• Notes from your doctor, teacher or other healthcare provider

• Medical history

• Test results

• Treatment notes

• Insurance information 

 

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared.

 

☐ I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.

 

☐ I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.

 

☐ I understand The Chat Room Speech-Language Pathology, APC cannot disclose my health information other than as specified in the notice.

 

☐ I understand that The Chat Room Speech-Language Pathology, APC reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.

 

_______________________________                                              _____________________

Print Name of Client                                                                Date

 

 

_______________________________                                              _____________________     

Signature of Participant or Legal Representative                      Relationship to Client

 

 

Please Note: It is your right to refuse to sign this Acknowledgement.

HIPAA Privacy Notice Acknowledgement

___________________________________________________________________

 

Office Use Only

 

I tried to obtain written Acknowledgement of our Privacy Notice by the patient/legal representative noted above. It could not be obtained for the following reason(s)

 

• An emergency prevented us from obtaining acknowledgement.

• The individual was unwilling to sign.

• A communication barrier prevented us from obtaining acknowledgement.

• Other: _________________________________

 

 

_______________________________                                              _____________________

Staff Member                                                                           Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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