Mt. Norris Counseling & Wellness, LLC

Jennifer M. Donohue, M.A., LCMHC Psychotherapist

Notice of Privacy Practices

As required by the Privacy Regulations created became of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

This notice describes how health information about you (as a client of this practice) may be made and disclosed, and how you can get access to the information.

Please review this notice carefully.

If you have any questions about this notice please contact Jennifer M. Donohue. M.A., LCMHC 802-851-1569

HIPPA Descriptions:

“In 1996, the US Congress recognized the importance of protecting the privacy of medical records when it passed the Health Insurance Portability and Accountability Act HIPPA), authorizing Congress to establish Uniform privacy standards for health information that is transmitted electronically.” “The privacy regulations establish that personal health information must be kept confidential. The regulations are designed to safeguard the privacy and confidentiality of a consumer’s health information, particularly in this age of rapid advances in technology and the subsequent ease with which information can be transmitted. The regulations establish a baseline of patient/client protections by defining the rights of individuals, the administrative obligations of covered entities, and the permitted uses and disclosures of protected health information. State laws that are stronger than the HHS privacy rule will remain in effect. In addition, state legislatures are afforded the opportunity to enact stronger protections in the future.” Quoted from Beth Powell’s article in the Volume II, Issue 1 of the 2002 VTMHCA Newsletter. This Notice of Privacy Practices describes how I may use and disclose your “Protected Health Information” (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. PHI is information about you, including demographic information that may identify you and that which relates to your past, present or future physical or mental health or condition and related health care services. My practice is dedicated to maintaining the privacy of your PHI. I am required to abide by the terms of this Notice of Privacy Practices. I may revise or amend the terms of this notice, at any time. The new notice will be effective for all PHI that I have at that time and for future information. I will post my current Notice in my office in a visible location at all times and upon your request, I will provide you with any revised Notice. Who Must Follow This Notice? As a “covered entity” under HIPPA, (a provider who bills electronically) I am subject to developing my own set of privacy and protocols. Here within are my protocols. DISCLOSURES 1. Use & Disclosure to Carry Out Treatment, Payment or Health Care Operations: Under HIPPA regulations, I do not need to obtain permission to use Health Information for treatment, payment and health care operations. However, several VT state laws require patient consent before health information is used or disclosed by health care providers. I may use and disclose your Protected Health Information (PHI) for the following reasons: A) Treatment: I will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. I attend regular clinical supervision with other community therapists and a Licensed Psychiatrist. This is a consultation and coordination so that I may provide the best care to you and to the overall success and support of your child. I will do everything to protect your personal information that is not necessary disclosures intended for the increase success and well-being of your child. I will not use or disclose any PHI without your written consent identified by a signature of self, parent or guardian consistent within service enrollment packet. B) Payment: Your protected health information will be used as needed to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services. I recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant health information be disclosed to the health plan to obtain approval for the hospital admission. C) Healthcare Operations: I may use or disclose, as needed, your protected health information in order to support the business activities of my practice. For example, ways I may disclose your PHI would be to return phone calls to your home and leave messages unless otherwise instructed by you, in writing not to do so. I may call you by name in the waiting room when I am ready to see you. I will strive to be very careful in such situations and you should discuss with me, any concerns you may have. I may share your PHI with third party “business associates” that may perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between any office and a business associate involves the use or disclosure of your PHI, I will have a written contract that contains terms that will protect the privacy of your PHI. D) Appointment Reminders: I may contact you to remind you of your appointment, returns calls, or leave a message to contact me. E) 1. Use and Disclosure You Can Agree or Object to: I may use and disclose your PHI in the following instances, which you have the opportunity to object. Others involved in your Healthcare: No information about your treatment will be released to others, not mentioned in the Notice, without written permission or otherwise required by law. Any party, other than those within this agreement, requesting information about you is responsible for obtaining a written release from you and sending it to me before any consultation will occur. In the case of an emergency, if you are unable to agree or object to such a disclosure, I may disclose such information as necessary if I determine that it is in your best interest based on my professional judgment. I may use of disclosure your PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care or that of your child of your location, general condition or death. Finally, I may use or disclose your PHI to an authorized public or private entity to assist in treatment efforts and to coordinate disclosures to family or other individuals involved in your health care. Emergencies: I may disclose your PHI in an emergency treatment situation. If this happens, I shall allow you to object to future disclosures as soon as reasonably practicable after the delivery of treatment. If you require more explanation or would like further elaboration in regards to types of emergencies where I will disclose your PHI please contact Jennifer M. Donohue, M.A., LCMHC at 802-793-2562. 2. Use and Disclosure That I Will Obtain Your Written Authorization For: Psychotherapy Notes: A file regarding your treatment will be maintained in a secure and locked location. The files may contain your signed counseling and billing contract for permission to treat and permission to bill our insurance company, billing information, HCFA forms with a diagnosis, and a treatment plan(s). Separate from this file there may be a file containing: treatment notes, mental health status exam, and a summary report. The file’s maintenance is a requirement for a period of five years following the end of treatment. In the event of my death, Jennifer Hirchak has been designated as a trusted individual to obtain the files and to maintain them. If this is a conflict of interest, please let me know and a note will be attached to the outside of the file with directions as to whom they must go. I will always obtain your written consent before your notes are released. You have the right to refuse that your notes be provided to an insurance company. 3. Use and Disclosure for Which an Authorization or Opportunity to Agree or Object to is Not Required: I may use or disclose your PHI in the following situations: Required By Law: There are legal exceptions for how I may use or disclose your PHI, to the extent that the use or disclosure is required by law, under which I must report to the appropriate authorities. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. The legal exceptions to the confidentiality rules are: 1) If there is a likelihood of serious harm to you or anyone else. 2) If I believe a child, elderly, or disabled person may be a victim of abuse, neglect, or exploitation. 3) In child custody dispute in which the court determines that the best interest of the child requires the therapist to breach confidentiality, the court may do so. 4) A judge’s court order. Public Health: I may disclose your PHI for public health activities and purposes to a public health authority that is required or permitted by law to receive the information. The disclosure will be made for the purpose of controlling or reporting disease, injury or disability. I may disclose your PHI, if directed by the pubic health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: I may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Abuse or Neglect: I may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, I may disclose your PHI if I believe that you have been a victim of abuse, neglect or domestic violence to the governmental agency or entity authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of the applicable federal and state laws. Health Oversight: I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigation, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Legal Proceedings: I may disclose PHI in the case of any judicial or administrative proceeding, in response to an order of a court by a judge. Law Enforcement: I may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of practice, and (5) medical/psychological emergency (not on the Practice’s premises) and it is likely that a crime has occurred. Criminal Activity: Consistent with applicable federal and state laws, I may disclose your PHI, if I believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. I may also disclose PHI if it is necessary for the law enforcement authorities to identify or apprehend an individual. Worker’s Compensation: I may disclose your protected health information (PHI) as authorized to comply with workers’ compensation laws and other similar legally established program. Inmates: I may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you. Required Use and Disclosures: Under the law, I must make disclosures to you and when required by the Secretary of the Department of Health and Humans Services to investigate or determine my compliance with the requirements of Section 164.500 et. Seq. Disclosures required by Vermont State Law: Vermont Law requires in the following cases: child abuse; abuse, neglect or exploitation of vulnerable adults; fire-arm related injuries; communicable diseases; fetal deaths; cancer; lead poisoning; blood-alcohol reporting; duty to warn of harm cases. I will disclose information limited to the relevant requirements of the law. Your Rights Following is a statement of your rights with respect to your personal health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of your PHI about you that is contained in a designated record set for as long as I maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your therapist and the practice use for making decisions about you. This may include psychotherapy notes. You must submit your request in writing to me in order to inspect and/or obtain a copy of your PHI. My practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your requests. My practice may deny your request to inspect and/or copy in certain circumstances; however, you may request a review of my denial. Please let me know if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask me not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. With this in mind, please discuss any restriction you wish to request with me. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply (e.g. insurance company). In an emergency, I am not required to agree to a restriction that you may request. If I believe it is in your best interest to permit the use and disclosure of your PHI, your PHI will not be restricted. You have the right to request that my practice communicate with you about your health and related issues in a particular manner or a certain location. For instance you may ask that I contact you at home, rather at work. You may request that I not leave messages on you answering machine, or with a family member. In order to request a type of confidential communication, you must make a written request specifying the requested method of contact, or the location where you will be contacted. My practice will accommodate reasonable requests. You do not need to give a reason for your request. You may have the right to have your therapist amend you protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as I maintain this information. In certain cases, for example if I think the information is correct, or was not created by my practice, I may deny your request for an amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me and I may prepare a rebuttal to your statements and will provide you with a copy of any such rebuttal. Please contact me to determine if you have questions about amending your medical record. To file an amendment, your request must be in writing. You have the right to a paper copy of this notice. You are entitled to receive a paper copy of my Notice of Privacy Practices even if you have agreed to receive an electronic copy of this Notice. You may ask me to give you a copy of this Notice at any time. You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with my practice or with the Secretary of the Department of Health and Human Services. To file a complaint with my practice, contact Diane Lafaille, Adminstrator, at (802) 828-2363. All complaints must be submitted in writing. You will not be penalized for filing a complaint.



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