JAXBCH Counseling

822 A1A North Suite 310, Ponte Vedra Beach, FL 32082

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCOLSED AND HOW YOU CAN GET ACCESS TO THIS INFORAMTION.  PLEASE REVIEW IT CAREFULLY.

I only release information in accordance with state and federal laws and the ethics of the counseling and or social work profession.  This notice describes my policies related to the use and disclosure of client’s healthcare information. 

“Use and disclosure of protected health information for the purposes of providing services.  Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.  State and federal laws allow me to use and disclose health information for these purposes.”

Treatment:  Use and disclose health information to:

• Provide, manage, or coordinate care
• Consultants
• Referral sources

Payment:  Use and disclose health information to:

• Verify insurance and coverage
• Process claims and collect fees

Healthcare Operations:  Use and disclose health information to:

• Review of treatment procedures
• Review of business activities
• Certification
• Staff training
• Compliance and licensing activities

Other Uses and Disclosures Without Your Consent: Use and disclose health information to:

• Mandated reporting
• Emergencies
• Criminal damage
• Appointment scheduling
• Treatment alternatives
• As required by law

Clients’ Rights

• Right to request where I contact you. On the informed consent you will circle which are ok to contact (home, cellphone, work).

• Right to release your medical records.

1. 1. *Written authorization to release records to others
   2. *Right to revoke release in writing
   3. *Revocation is not valid to the extent that you have acted in reliance on such previous authorization

• Right to inspect and copy your medical billing records

1. 1. *Right to inspect and copy records
   2. *Counselor may deny this request
   3. *Charges for copying, mailing, etc.

• Right to add information or amend your medical records.

1. 1. *May request to amend record within 14 days of review
   2. *Counselor may deny this request but you have the right to file a
   3.  disagreement statement which will be filed in your record along with your response.
   4. *Amendment request must be in writing

• Right to accounting of disclosures.

1. 1. *For a six year period
   2. *Exceptions:
   3. *Disclosure for treatment, payment, or healthcare operations
   4. *Disclosures pursuant to a signed release
   5. *Disclosure made to client
   6. *Disclosures for national security or law enforcement

• Right to request restriction on uses and disclosures of your healthcare information.

1. 1. *Must be in writing
   2. *You are not obligated to agree

• Right to complain.

1. 1. *Please contact me first to try and resolve.
   2. *If you are not satisfied, you have the right to complain to the US Dept. of Health and Human Services 
   3. *No retaliation

• Right to receive changes in policy

1. 1. *May request any future changes
   2. *Request to privacy office (Melissa Dionne, LCSW)