THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal program that requests 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, the right to understand and control how your personal health information (“PHI”) is used. HIPAA provides penalties for covered entities that misuse personal health information.

OUR COMMITMENT REGARDING HEALTH INFORMATION

We understand that health information about you is personal. We are committed to protecting health information about you. Choice Psychiatry Medical Group (SPMG) will create a record of the services you receive at our offices.  We need this record to provide you with quality services and to comply with certain legal requirements. We are required by law to make sure that health information that identifies you is kept private; Give you this notice of our legal duties and privacy practices regarding health information about you; and follow the terms of the notice that is currently in effect.

DISCLOSURE OF HEALTH INFORMATION ABOUT YOU WITH AND WITHOUT YOUR AUTHORIZATION

For Law Enforcement purposes: We will disclose health information about you when required to do so by federal, state or local law.

For Public health concerns: We will disclose health information about you for public health reporting required by federal or state law. These activities generally include the following: To prevent or control disease, injury or disability; To report deaths; To report potential/ actual child abuse or neglect ; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; To notify the appropriate government authority if we believe an individual served has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

For Health Oversight Activities: These oversight activities include, for example, audits, investigations, inspections, and licensure.

For Legal Proceedings: If you are involved in a lawsuit or a dispute, we will disclose health information about you when properly ordered to do so by a court or law enforcement. We will

release health information if asked to do so by a law enforcement official, and if permitted by law: In response to a court order; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at the office of SPMG. In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

OTHER WAYS WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITH AND WITHOUT YOUR WRITTEN AUTHORIZATION

The following categories describe different ways that we use and disclose health information:

For Treatment: We may use health information about you to provide you with clinical treatment or services. We may disclose health information about you to clinical providers and support staff personnel who are involved in providing services to you.

For Payment: We may use/disclose health information about you so that the services you received through SPMG may be billed to, and payment may be collected from you, an insurance company or a third party. For example, we may need to give your insurance company information about services you received at SPMG in order to receive payment. We may also tell your insurance about a service you are going to receive to obtain prior authorization or to determine whether your insurance will pay for the service.

For Health Care Operations: We may use/disclose health information about you to another health care provider or health plan, if you have given us written authorization to do so.

For Appointment Reminders: We may use and disclose health information about you to contact you as a reminder that you have an appointment with clinician at SPMG. You have a right to request confidential communications in a specific manner or at a specific location. Please remember you will need to inform us in writing if you do not wish to be contacted for the purposes of appointment reminders. Staff will be available to assist you on completing this written request.

For Treatment Alternatives: We may use and disclose health information to tell you about or recommend possible treatment opt ions or alternatives that may be of interest to you.

For Research: Under certain circumstances we may use/disclose health information about you for research purposes. Before we use/disclose information about you that reveals who you are (name/ address) we will obtain your written authorization.

For Health-Related Benefits and Services: We may use and disclose health information to tell you about health- related benefits or services that may be of interest to you.

For Individuals Involved in Your Care or responsible for Payment for Your Care: We may release certain limited information about you to a family member who is your parent or guardian as allowed by federal and state law. We may also give information to a parent or guardian that is responsible to pay for the services you are provided through SPMG. We may disclose health information about you to an entity assisting in a disaster relief effort so your family can be notified about your condition, status, and location.

SPECIAL SITUATIONS

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Coroners/Medical Examiners: We may release health information to a coroner/medical examiner. This may be necessary, i.e. to identify the cause of death.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. This release would be 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) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

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

To Inspect and Copy: You have the right to inspect and copy your Protected Health Information. To exercise this right, you must submit your request, in writing, to SPMG. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy under limited circumstances. If we deny you access to your PHI, you may in some cases request review of the denial. SPMG will choose a licensed healthcare professional (who did not take part in denying your request) to review your request and the denial. We will comply with the outcome of the review.

To Request to Amend: The health information we have about you if you feel that it is incorrect or incomplete. You have a right to request an amendment for as long as the information is kept by SPMG. To request an amendment, your request must be made in writing and submitted to HMA.  In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include the reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

To Request Restrictions: On the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the heath information we disclose to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to SPMG. In your request, you must tell us (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply.

Right to Request Confidential Communications: You have a right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to SPMG. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

PRIVACY COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with administrator of SPMG or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

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 health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on the website and will also be available in the office. If you have any questions about this notice, please contact SPMG at

951-356-5414.