NOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND
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1 NOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND
2 THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Introduction: Karen P. Freed, LCSW-C, BCD (KPF) is committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information that is collected and how and when it is used or disclosed. It also describes your rights as they relate to your protected health information. This Notice is effective and applies to all protected health information that is defined by federal regulations. Understanding Your Health Record/Information Each time you visit KPF a record of your visit is made. Typically, this record contains your symptoms, any test results, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record serves as: -Basis for planning your care and treatment -Means of communication among the many health professionals who contribute to your care -Legal documents describing the care you received -Means by which you or a third-party payer can verify that services billed were actually provided -A tool with which we can assess and continually work to improve the care that is rendered and the outcomes achieved Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others. Your Health Information Rights Although your health record is the physical property of Karen P. Freed, LCSW-C, BCD, the information belongs to you. You have the right to: -Inspect and receive a copy of your health record as provided for in 45CFR (This provision is part of the HIPAA Privacy Regulations. We have not listed in this Notice all of the activities included within these definitions, so please refer to the appropriate subsection of the Act.) -Amend your health record as provided in 45CFR Obtain an accounting of disclosures of your health information as provided in 45CFR 164 -Request communication of your health information by alternative means or at alternative locations -Request a restriction on certain uses and disclosures of your information as provided by 45CFR and -Revoke your authorization to use or disclose health information except to the extent that action has already been taken KPF RESPONSIBILITIES KPFis required to: -Maintain the privacy of your health information -Provide you with this notice as to the legal duties and privacy practices with respect to information that is collected and maintained about you -Abide by the terms of this notice -Notify you if KPF is unable to agree to a requested restriction and
3 p.2 -Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations KPF reserves the right to change practices and to make the new provisions effective for all protected health information that is maintained. Should the information practices change, a revised notice will be mailed to the address you ve supplied. KFP will not use or disclose your health information without your authorization, except as described in this notice. KPF will also discontinue to use or disclose your health information after KPF receives a written revocation of the authorization according to the procedures included in the authorization. For More Information or to Report a Problem If you have questions and would like additional information you may contact the practice s Privacy Officer, Karen P. Freed. If you believe your privacy rights have been violated, you can file a complaint with the practice s Officer or with the Office for Civil Rights, US Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer of the Office for Civil rights. The address for the OCR is listed below: Office for Civil Rights US Department of Health and Human Services 200 Independence Avenue SW Room 509 F, HHH Building Washington DC Examples of Disclosures for Treatment, Payment and Health Operations KPF will use your health information for treatment. For example: Information obtained will be recorded in your record and used to determine the course of treatment that should work best for you. Treatment goals will be documented and assessed as well as progress. KPF will also provide subsequent health care providers with copies of various reports that should assist them in your treatment. This is to include all health care providers utilized in consultation and those assisting in coverage of KPF s practice. Your health information will be used for payment. For example: This information will be used to assess the care and outcomes in your case. This information will be used in an effort to continually improve the quality and effectiveness of the health care and services provided. Notification: KPF may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. KPF may leave a message on your answering machine or on a voic as a means of communication. KPF may mail you a letter as a means of communication or utilize . Communication with family: Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person s involvement in your care or payment related to your care.
4 p.3 Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Public Health: As required by law, KPF may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Law Enforcement: KPF may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that KPF has engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
5 Notice of Privacy Practices Receipt and Acknowledgement of Notice Client Name: DOB: SSN: I hereby acknowledge that I have received and have been given an opportunity to read a copy of Karen P. Freed s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights I can contact Karen P. Freed, Privacy Officer at Whippoorwill Lane, North Bethesda, Maryland 20852, Signature of Client Signature of Parent, Guardian or Personal Representative* *If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.) Client Refuses to Acknowledge Receipt: Signature of Staff Member
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