New Hope Mental Health Counseling P.C. (the “Company” is providing this Notice of Privacy Practices (“Notice”) and Disclosure because the privacy of your Protected Health Information (“PHI”) is very important to you and to us, and in compliance with Federal and State Regulations.
By “your PHI” we mean the information that we maintain that specifically identifies you and your health status or services.
This Notice describes how we use your PHI within the Company and disclose it outside the Company and why. This Notice covers:
I. Uses or disclosures which do not require your written authorization:
A. Treatment, Payment and Healthcare Operations:
To carry out your treatment, to obtain payment and to conduct health care operations. For example:
- For treatment, we use your PHI to plan, coordinate, and provide your care. We disclose your PHI for treatment purposes to physicians and other health care professionals outside of our agency who are involved in your continued care.
- For payment, we use your PHI to prepare documentation required by your third-party payer (your insurance company).
- For healthcare operations, we use or disclose your PHI, for example, to improve the quality of our services, to plan better ways of treating patients, to evaluate staff performance and oversee the Company’s operation by an accredited agency.
- Uses or Disclosure of Your PHI to Which You May Object:
We may use or disclose your PHI for the following purposes, unless you ask us not to:
- Disclose your PHI to family, friends, or others identified by who are involved in your care.
- Assistance in disaster relief efforts.
- Confirming our visits to your home or other appointments.
- Informing you about treatment alternatives or other health-related benefits and services that may be of interest to you.
If you object to our use or disclosure of your PHI for any of these purposes please do so in writing to the Administrator of your local New Hope Mental Health Counseling P.C. service office.
- Uses or Disclosures Required or Permitted:
Where we are required or permitted to do so, we may use or disclose your PHI in the following circumstances without your written authorization.
1 Federal, State or Local law requirements
2. Federal government investigation when required by the Secretary of Health and Human Services to investigate or determine our compliance with federal and State regulation.
3. Public health activities, for example to report communicable disease or death; or for matters involving the Food and Drug Administration.
4. Reporting of abuse, neglect or domestic violence.
5. Health oversight activities by a health oversight agency. (A health oversight agency is an organization authorized by the government to oversee eligibility and compliance and to enforce civil rights laws.)
6. Judicial or administrative proceedings, for example responding to a court order of subpoena.
7. Law enforcement purposes, for example tor report certain types of wounds or other physical injuries or to indentify or locate a suspect, fugitive, material witness or missing person.
8. Use by coroners, medical examiners or funeral directors.
9. Facilitating organ or tissue donation.
10. Research, provided that very strict controls are enforced.
11. Averting a serious threat to your health or safety or that of the public.
12. Workers compensation.
II. Uses or disclosures which require your written authorization
Your written authorization, which you may revoke (in writing) is required if we use or disclose your health information for NON Treatment, Payment, or Healthcare Operations.
A. Our use of psychotherapy notes beyond treatment, payment, and healthcare operations.
B Marketing of goods or services to you.
C. To other parties and/or organizations beyond treatment, payment and other healthcare operations.
III. Your Rights As A Patient to Privacy of Your PHI
A. You have the rights to request restriction(s) on our uses and disclosures of your PHI; we may however refuse to accept the restriction(s), if the restrictions(s) are deemed unreasonable.
B. You have the right to request that we communicate PHI with you confidentially or with an individual you identify. For example to speak with you or an individual you identify only in private, to send email to an address you designate or to telephone you at a number you designate.
C. You have the right to request access to your PHI in order to inspect or copy it.
D. You have the right to request in writing an amendment of your PHI providing a justifiable reason for the amendment. If we deny your request, you may submit a statement of disagreement.
E. You have the right to request an accounting of our disclosures other than treatment, payment, and healthcare operations. We are not required to provide an accounting for disclosures before April 14, 2003, or for more than six years prior to the date of your request.
F. If you have received this Notice electronically, you then have the right to receive a paper copy.
Your request for any of the above must be in writing. We may deny your request and, if so, you may request a review of the denial. We will however, make every attempt to honor your
request. A nominal fee for copying and supplies would be applied if there were more than one request per year.
IV) Our Duties in Protecting Your PHI:
A. We are required by law to maintain the privacy of your PHI.
B. We must inform patients or their legal representatives of our legal duties and privacy practices with respect to PHI. This Notice discharges that duty.
C. We must abide by the terms of the Notice currently in effect.
D. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain. You may obtain a copy of the current Notice form at any time.
V) Complaints Contact Person, Effective Date and Acknowledgment:
A You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated.
B. You will not be retaliated against for filing a complaint.
C. You may file your request or complain t with our company by writing to:
C/o New Hope Mental Health Counseling P.C.
70-01 Metropolitan Avenue
Middle Village, New York 11379
D. You may file a complaint with the Secretary of Health and Human Services by writing to
Secretary of Health and Human Services, Officer of Civil Rights
US Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
VI) Disclosure and Practices
A. Intake Interview: In this interview your presenting problems are explored and evaluated. Recommendations for use of the center’s services are given. It is occasionally necessary for this interview to be followed up by supplementary diagnostic work when this happens there will be a case review, findings and recommendations will be fully discussed with you.
B. Counseling Orientation: The therapist at New Hope Mental Health Counseling P.C.’s approach to counseling is an eclectic mix of cognitive behavioral, psychodynamic, gestalt, object relations and client centered. You and your therapist will work together and reflect on your life story so that you are more capable to choose the life you want to live. In addition to exploring the issues that bring you to counseling, your therapist may also look at your relationships with other significant people in your life. The work between you and your therapist may also focus on the ways that you thrive in relationships and also the areas where you are hindered from reciprocity and enjoyment in your relationships. Your therapist’s role is to create a safe space for you to locate and live out your truest self. Your therapist will work together to identify the hindrances and obstacles preventing you from living your most meaningful and authentic life. Your ability to be open and honest with your therapist will greatly enhance the effectiveness of your therapy. In addition, certain problems can have a physical component. In such cases, medical consultation will be advised. If at any point you have questions or concerns about our relationship or the direction of our work together, please feel free to address them with your therapist.
C. Insurance: It is the patient’s responsibility to know the limits of their health plan coverage for mental health. Co-pays are due at the time of visits. Any unpaid balances or deductibles for services rendered at New Hope Mental Health Counseling P.C. are the patient’s responsibilities. If for any reason insurance checks are made payable to the patient, it is the patient’s legal responsibility to endorse checks to New Hope Mental Health Counseling P.C. upon receipt. Please note that insurance is not a guarantee of payment.
D .Missed Appointments: In the event that you are unable to keep an appointment, please notify the center via phone a minimum of (24 hours) in advance. If you miss your appointment for whatever reason and fail to give me adequate notice, you will be responsible for a 60.00 for the session. If you are late, your therapist will stop at our regular ending time in order to keep his or her schedule, and you will still be required to pay for the entire session. In the event of a missed appointment, the bill will reflect a late cancellation instead of a clinical session. If your therapist has an emergency, he or she will notify you as soon as possible of their need to reschedule your appointment.
E. Termination of Treatment: When you wish to terminate treatment, please give a minimum of one week’s notice. You may terminate treatment at any time without moral, legal, or financial obligation beyond payment of services already rendered. It is expected that your therapist will discuss the prospect of termination so that both parties will be clear about any details that need attention as part of the termination process.
F. Therapist at New Hope Mental Health Counseling P.C.: Please note that the therapist at New Hope Mental Health Counseling P.C. are independent contractors of New Hope Mental Health Counseling P.C. These independent contractors are either licensed psychiatrist, psychologist, clinical social workers, marriage and family therapist, mental health counselor and has obtained and maintained all permits, licenses, approvals authorizations and registrations. Patient shall hold harmless New Hope Mental Health Counseling P.C. against any and all claims, liabilities, damages or judgments that arise out of any acts of the Independent Contractor.
G. Crisis/ Emergency Situations: If you have a crisis or an emergency situation please do not hesitate to call the office in attempts to schedule an emergency appointment with your therapist. If your therapist is not available we will try and schedule you an appointment with another available clinician. If it is after hours please note that in an emergency situation you are directed to dial 911. If you are having any suicide ideations please also call the National Suicide Hotline at 800/273-8255. Please make sure you discuss any of these matters with your therapist on your next visit.
This Notice is effective November 2012