Berkshire Speech + Language | 5 Thrushwood Lane | Great Barrington, MA 01230 | 413-884-4758 | email@example.com
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. (HIPAA, sec 164.520)
This private practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information (PHI) is the information we create and obtain in providing my services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes
We may use your PHI to provide and manage your health care.
If we refer you for other treatment to another clinician or hospital, we will provide that health care provider with the necessary information to diagnose or treat you.
Sharing your PHI with other health care providers who may consult with us about your care.
Example of Use of Your Health Information for Payment Purposes
We may use and disclose your Health Information, as needed, to obtain payment for health care services.
We may disclose information to your insurance company or third party payer in order to make sure your treatment is approved, to verify eligibility or coverage for insurance benefits, and to permit the payer to review services provided to you for medical necessity.
We may need to share relevant Health Information to your health plan to obtain approval for continuing authorizations.
Example of Use of Your Information for Health Care Operations
We may use or disclose your Health Information in order to conduct my business of providing speech-language pathology services.
These health care operations may include quality assessment, training of students, credentialing and various other activities that are necessary to run our practice and to improve the quality and cost effectiveness of the care that we provide to you.
We may obtain services from my insurer or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
Your Health Information Rights
The health and billing records we maintain are the physical property of the Berkshire Speech Language. The information in it, however, belongs to you. You have a right to:
- Inspect and copy your Health Information at any time. Under limited circumstances we may limit your access to all or certain portions of your record. This includes, but is not limited to, process notes, or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. All requests to access your record must be made in writing to your speech-language pathologist, and will be processed within 30 days.
- Request a restriction on certain uses and disclosures of your health information by delivering the request to my office – We are not required to grant the request, but we will comply with any request granted;
- Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full-we must comply with this request;
- Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at my office;
- Appeal a denial of access to your protected health information, except in certain circumstances;
- Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office. 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;
- Is not part of the health information kept by or for the office;
- Is not part of the information that you would be permitted to inspect and copy; or,
- Is accurate and complete.
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;
Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office;
Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.
Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office, except to the extent information or action has already been taken.
If you want to exercise any of the above rights, please contact Andrea S. White, MEd, MA, CCC-SLP, Berkshire Speech + Language, 5 Thrushwood Lane, Great Barrington, MA 01230; 413.884.4836, in person or in writing, during regular, business hours. We will inform you of the steps that need to be taken to exercise your rights.
Our office is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restriction or request; and,
- Accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If my information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting my office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Andrea S. White, MEd, MA, CCC-SLP, Berkshire Speech + Language, 5 Thrushwood Lane, Great Barrington, MA 01230; 413.884.4836.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Andrea S. White, MEd, MA, CCC-SLP, Berkshire Speech + Language, 5 Thrushwood Lane, Great Barrington, MA 01230; 413.884.4836. You may also send a written complaint to the Director, Office for Civil Rights of the US Department of Health and Human Services.
We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Other Disclosures and Uses
Communication with Family
Using our best judgment, we 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 in payment for such care if you do not object or in an emergency.
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under “Your Health Information Rights.”
This Notice is posted on Berkshire Speech + Language’s website: www.BerkshireSpeech.com.