This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

PLEASE REVIEW THIS NOTICE CAREFULLY

Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present or future physical health, mental health, or other condition, and the related health care services, is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, and the obligations we have regarding the use and disclosure of PHI. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time, and any revised Notice of Privacy Practices will be effective for all PHI that we maintain at that time. Should we revise any part of our Notice of Privacy Practices at any time, we will notify you immediately by sending you an updated copy through the secure client portal and will post an updated copy on our website. We will send a copy to you in the mail upon request. You have the right to ask questions or discuss this notice with a staff member prior to signing.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. We may disclose PHI to health care professionals outside of Apricity Mental Health only with your authorization.

For Payment: We may use or disclose PHI so that we can receive payment for the treatment services provided to you. Examples of payment-related activities include but are not limited to: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. By voluntarily engaging in treatment utilizing your health insurance (whether in or out of network), you are acknowledging that we are bound to act in accordance with the requirements outlined in our contract with your health insurance company. This includes the manner in which we file insurance claims and related PHI or treatment details in order to collect payment for services rendered. Your insurance company may also request documentation from your chart to ensure you meet criteria for ongoing services and payment or to meet state guidelines, or to conduct mandated audits or reviews of their members. Apricity Mental Health will release these records only as requested, directly to your insurance company or their hired certified third-party contractor. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. For any chargebacks filed, we may be required to provide your bank with proof of your signed payment agreement or other related documentation, but will release the minimum amount of information necessary.

For Health Care Operations: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing, accounting, or typing services) provided we have a written contract with that person or business in order to safeguard the privacy of your PHI. For training or teaching purposes, PHI will be disclosed only with your authorization.

As Required by Law: Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

The following is a list of the categories of uses and disclosures of your PHI permitted by HIPAA without an authorization:

-Abuse or neglect;

-Judicial and administrative proceedings;

-Emergencies;

-Law enforcement activities;

-National Security;

-Public Safety (Duty to Warn).

Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. The types of uses and disclosures that may be made without your authorization include but are not limited to:

-Disclosures required by law, such as the mandatory reporting of child or elder abuse or neglect, or mandatory government agency/ public health audits, investigations, or oversight activities;

-Disclosures required by court order, subpoena, or in response to valid judicial or administrative orders or request from law enforcement, when required by law;

-Disclosures necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. This also includes disclosures necessary to prevent any imminent risk to your own well being, such as active suicidal thoughts or gestures that are assessed and clinically indicative of a risk to your life;

-Disclosures that are relevant and necessary for the defense of Apricity mental Health or any of its staff or related associates should a client file a complaint or lawsuit of any kind;

-Disclosures regarding treatment as it relates to and is necessary for a worker's compensation claim filed by a client, to the appropriate parties such as the client’s employer, the insurance carrier, or an authorized qualified provider involved in the case.

Verbal Permission: We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time.

YOUR RIGHTS REGARDING YOUR PHI

In most cases, you have certain rights regarding your PHI within the designated record set maintained by Apricity Mental Health, as defined by the OCR Privacy Rule. To exercise any of these rights, please submit your request in writing to your clinician or any member of the staff.

Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.

Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.

Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.

Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

Right to a Copy of this Notice: You have the right to a copy of this Notice.

COMPLAINTS

If you are concerned that your privacy rights may have been violated, feel that there has been a lack of compliance with the Privacy Rule or the privacy policy and procedures of this company, or disagree with a decision made about access to your records, you may contact our Privacy Officer (listed below). You also may send a written complaint to the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights. Our Privacy Officer will provide you with the address at your request. We will never retaliate against you for filing a complaint or exercising any right guaranteed to you by the Privacy Rule.

Privacy Officer for Apricity Mental Health:

Brittany Richstein, LCSW, LCADC

908 774 9884 | brichstein@apricitymentalhealth.com

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