Robert S. Miller, LICSW, ACSW
275 SE Cabot Drive, Suite B-206
Oak Harbor, WA
98277-3755
360.240.8090
HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your
health. This information, that may
identify you and that relates to your past, present or future physical or
mental health or condition and related health care services, is referred to as
Protected Health Information (“PHI”). This Notice of Privacy Practices
describes how I may use and disclose your PHI in accordance with applicable law
and the National Association of Social Workers (NASW) Code of Ethics. It also describes your rights regarding how
you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you
with notice of my legal duties and privacy practices with respect to PHI. I am
required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of
my Notice of Privacy Practices at any time.
Any new Notice of Privacy Practices will be effective for all PHI that I
maintain at that time. I will provide you with a copy of the revised Notice of
Privacy Practices by posting a copy on my website at www.geocities.com/robert_scott_miller,
sending a copy to you in the mail upon request, or providing one to you at your
next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT
YOU
For Treatment. Your PHI may be used and disclosed by
those who are involved in your care for the purpose of providing, coordinating,
or managing your health care treatment and related services. I may disclose your PHI to physicians, psychiatrists,
psychologists, and other licensed health care providers who provide you with
health care services or are otherwise involved in your care. Example: If a
psychiatrist is treating you, I may disclose your PHI to her/him in order to
coordinate your care.
For Payment. I may use and disclose PHI so that I can
receive payment for the treatment services provided to you. This will only be done with your
authorization. Examples of payment-related activities are: making a
determination of eligibility or coverage for insurance benefits, processing
claims with your insurance company, reviewing services provided to you to
determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection
processes due to lack of payment for services, I will only disclose the minimum
amount of PHI necessary for purposes of collection.
For Health Care
Operations. I may use or
disclose, as needed, your PHI in order to support my business activities
including, but not limited to, quality assessment activities, licensing, and
conducting or arranging for other business activities. For example, I may share
your PHI with third parties that perform various business activities (e.g.,
billing services) provided I have a written contract with the business that
requires it to safeguard the privacy of your PHI.
Required by Law. Under the law, I must make disclosures of your
PHI to you upon your request. In
addition, I must make disclosures to the Secretary of the Department of Health
and Human Services for the purpose of investigating or determining my
compliance with the requirements of the Privacy Rule.
Without Authorization. Applicable law and ethical standards permit
me to disclose information about you without your authorization only in a
limited number of other situations. The
types of uses and disclosures that may be made without your authorization are
those that are:
·
As required by law to report health care information; when needed to
determine compliance with state or federal licensure, certification or
registration rules or laws; or when needed to protect the public health;
·
To federal, state, or local law enforcement authorities to the extent
the health care provider is required by law, such as the mandatory reporting of
child abuse or neglect or mandatory government agency audits or investigations
(such as the social work licensing board or the health department);
·
Required by Court Order;
·
Necessary to prevent or lessen a serious and imminent threat to the
health or safety of a person or the public.
If information is disclosed to prevent or lessen a serious threat it will
be disclosed to a person or persons reasonably able to prevent or lessen the
threat, including the target of the threat.
Verbal Permission. I may use or disclose your information to
family members that are directly involved in your treatment with your verbal
permission.
With Authorization. Uses and disclosures not specifically
permitted by applicable law will be made only with your written authorization,
which is valid for 90 days, unless revoked sooner.
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please
submit your request in writing to me, Robert S. Miller (Privacy
Officer) at 275 SE Cabot Drive, Suite B-206, Oak Harbor, WA 98277-3755:
Right of Access to
Inspect and Copy. You have the right,
which may be restricted only in exceptional circumstances, to inspect and copy
PHI that may be used to make decisions about your care. You will receive a written response from me
within 15 days of my receiving your written request. Your right to inspect and copy PHI will be restricted only in
those situations where there is compelling evidence that access would cause
serious harm to you. If you ask for
copies of your PHI, I may charge you eighty-three ($.83) cents for the first 30
pages and sixty-three ($.63) per page for all additional pages. I may see fit to provide you with a summary
or explanation of the PHI, but only if you agree to it, as well as to the cost,
in advance. Other charges may apply
(see WAC 246-08-400).
Right
to Amend. If you feel that the
PHI I have about you is incorrect or incomplete, you may ask me to amend the
information although I am not required to agree to the amendment. You will receive a response within 10 days
of my receipt of your written request.
If I deny your request, I must state my reasons for the denial in
writing.
Right to an Accounting
of Disclosures. You are entitled to a
list of disclosures of your PHI that I have made. The list will not include uses
or disclosures to which you have already consented, i.e., those for treatment,
payment, or health care operations, sent directly to you, or to your family;
neither will the list include disclosures made for national security purposes,
to corrections or law enforcement personnel, or disclosures made before April
15, 2003. After April 15, 2003,
disclosure records will be held for six years.
I will respond to your
request for an accounting of disclosures within 30 days of receiving your
request. The list will include the date
of the disclosure, to whom PHI was disclosed (including their address, if
known), a description of the information disclosed, and the reason for the
disclosure. I will provide the list to you at no cost, unless you make more
than one request in the same year, in which case I will charge you a reasonable
sum based on a set fee for each additional request.
Right
to Request Restrictions. You have the right to
request a restriction or limitation on the use or disclosure of your PHI for treatment,
payment, or health care operations. I
am not required to agree to your request.
You do not have the right to limit the uses and disclosures that I am
legally required or permitted to make.
Right
to Request Confidential Communication. You have the right to
request that I communicate with you about medical matters in a certain way or
at a certain location.
Right
to a Copy of this Notice. You have the right to
a copy of this notice.
COMPLAINTS
If you believe I have violated your privacy rights, you have the right
to file a complaint in writing with me, or with the Secretary of Health and
Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201, or by calling (202) 619-0257. I will not retaliate against you for
filing a complaint.
The effective date of this Notice is April 14,
2003.