NOTICE OF PRIVACY PRACTICES
Effective Date: 7/1/2021
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices (“Notice”) apply to MaeWorks Psychotherapy Solutions, its affiliates and its Owner, Jason Maedl, LMFT ("I").
I will share protected health information of clients as necessary to carry out treatment, payment, and health care operations as permitted by law.
I am required by law to maintain the privacy of clients' protected health information and to provide clients with notice of my legal duties and privacy practices with respect to protected health information. I am required to abide by the terms of this Notice for as long as it remains in effect. I reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by MaeWorks Psychotherapy Solutions. I am required to notify you in the event of a breach of your unsecured protected health information. I am also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION:
Authorization and Consent: Except as outlined below, I will not use or disclose your protected health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once I actually receive the writing; however, such revocation shall not be effective to the extent that I have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
Uses and Disclosures for Treatment: I will make uses and disclosures of your protected health information as detailed in the Informed Consent and Practice Policies document. Doctors and nurses and other professionals involved in your care might use information in your record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, and other forms of treatment data.
Uses and Disclosures for Payment: I will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, I may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. I may also use your information to prepare a bill to send to you or to the person responsible for your payment. I may supply information to collection agencies should there be a need to settle unpaid invoices.
Uses and Disclosures for Health Care Operations: I will make uses and disclosures of your protected health information as necessary, and as permitted by law, for my operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, I may use and disclose your protected health information for purposes of improving clinical treatment.
Individuals Involved In Your Care: I may from time to time disclose your protected health information to specifically designated and authorized family, friends and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and I determine that a limited disclosure may be in your best interest, I may share limited protected health information with such individuals without your approval. I may also disclose protected health information to emergency services or crisis service providers in a situation which I believe threatens your safety or the safety of another person. I may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of my services may be performed through contracts with outside persons or organizations, such as accreditation, outcomes data collection, legal services, etc. At times it may be necessary for to provide your protected health information to one or more of these outside persons or organizations who assist us with health care operations. In all cases, I require these associates to appropriately safeguard the privacy of your information. In addition to the measures I take, associate technology providers are covered by specific Business Associate Agreements that safeguard your protected health information.
Appointments and Services: I may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and I will accommodate reasonable requests by you to receive communications regarding your protected health information.
Other Uses and Disclosures: I am permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:
• Any purpose required by law;
• Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations;
• If I suspect child abuse or neglect;
• If I suspect significant risk of self-harm or harm to another person;
• Court or administrative ordered subpoena or discovery request;
• To coroners and/or funeral directors consistent with law;
• If you are a member of the military, I may also release your protected health information for national security or intelligence activities;
• To worker's compensation or disability agencies for workers' compensation benefit determination.
DISCLOSURES REQUIRING AUTHORIZATION:
Psychotherapy Notes: I must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which I may disclose psychotherapy notes, without obtaining your written authorization, including the following:
(1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, to defend myself in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public (duty to warn).
Genetic Information: Course of care does not include collection of genetic information.
Marketing: I will not disclose any information for the purpose of marketing.
Sale of Information: I will not sell your information for any reason or purpose.
Remuneration for Information Disclosure
I may require or request remuneration for costs related to the following:
• Public health activities;
• Research purposes, provided that I receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes;
• Treatment and payment purposes;
• Health care operations involving the sale, transfer, merger or consolidation of all or part of business and for related due diligence;
• Payment I provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on my behalf (or the subcontractor undertakes on behalf of a business associate) and the only remuneration provided is for the performance of such activities;
• Providing you with a copy of your health information or an accounting of disclosures;
• Disclosures required by law;
• Disclosures of your health information for any other purpose permitted by and in accordance
with the Privacy Rule of HIPAA, as long as the only remuneration I receive is a reasonable,
cost-based fee to cover the cost to prepare and transmit your health information for such
purpose or is a fee otherwise expressly permitted by other law
• Any exceptions allowed by the Department of Health and Human Services.
RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:
Access to Your Protected Health Information: You have the right to copy and/or inspect much of the
protected health information that I retain on your behalf. For protected health information that I maintain
in any electronic designated record set, you may request a copy of such health information in a reasonable
electronic format, if readily producible. Requests for access must be made in writing and signed by you or
your legal representative. You may be charged a reasonable copying fee and actual postage and supply costs for your
protected health information. If you request additional copies you may be charged a fee for copying and
postage.
Amendments to Your Protected Health Information: You have the right to request in writing that
protected health information that I maintain about you be amended or corrected. I am not obligated to
make requested amendments, but I will give each request careful consideration. All amendment requests,
must be in writing, signed by you or legal representative, and must state the reasons for the
amendment/correction request. If an amendment or correction request is made, I may notify others who
work with me if I believe that such notification is necessary.
Accounting for Disclosures of Your Protected Health Information: You have the right to receive an
accounting of certain disclosures made. Requests must be made in writing and signed by you or your legal representative.
Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to
request restrictions on uses and disclosures of your protected health information for treatment, payment, or
health care operations. I am not required to agree to most restriction requests, but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid MaeWorks Psychotherapy Solutions in full. If I agree to any discretionary restrictions, I reserve the right to remove such restrictions as I deem appropriate. I will notify you if I remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records.
Right to Notice of Breach: I take very seriously the confidentiality of my clients’ information, and I am required by law to protect the privacy and security of your protected health information through appropriate safeguards. I will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.
Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to the address below.
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For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the MaeWorks Psychotherapy Solutions by phone at 585.358.0258 or at the following address: 95 Allens Creek Road, Building 2, Suite 203 Rochester NY 14618.