The House of Hope

The House of Hope

Notice of Privacy Practices

(HIPPA and Minnesota Law) Effective April 14, 2003

JillM.Ellingson,MA,LMFT

8944IndahlAve.South-CottageGrove,MN

612-242-1224

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

TheHealthInsurancePortabilityAccountabilityActof 1996 (HIPAA)is a federalprogramwhich requiresthatallmedicalrecordsandotherindividuallyidentifiablehealth information usedor disclosedbyBraveSoulCounselingServices,in anyform,whetherelectronically,on paperororally,arekeptproperlyconfidential.ThisActgivesyou,theclient,significantnewrights to understand and controlhowyourhealthinformation isused.HIPAAprovidespenaltiesforcoveredentitiesthatmisusepersonalhealth information.

Asrequired by HIPAA,BraveSoulCounseling Serviceshasprepared thisexplanation ofhowwearerequiredtomaintain theprivacy ofyourhealth information and howwemayuseand discloseyourtreatmentinformation.Thetermswe,our and usrefertoBraveSoulCounseling Servicesand thetermsyouand yourreferto our clients.

Protected Health Information (PHI)is:

1.Information aboutyourmental or physicalhealth,related healthcareservicesorpaymentforhealth careservices

2.Informationthatisprovided byyou,created byus,orshared with usbyrelatedorganizations

3.Informationthatidentifiesyouor could beused toidentifyyou,such asdemographicinformation,addressphonenumber,age,dateofbirth,dependentsand health history.

Wemay useand discloseyourpersonalhealth informationonlyforeachof thefollowing purposes:treatment,paymentand health-careoperations.

  • Treatmentmeansproviding,coordinating ormanaginghealth careand related servicesby oneormorehealthcaretherapists. Anexampleofthiswould includetreatmentsession notes,appointmentremindersorotherhealth-relatedbenefitsandservicesthatmaybeof interestto you.
  • Paymentmeansactivitiessuch asobtaining reimbursementforservices,confirming coverage,billing orcollectionactivities. Anexampleofthiswould bedisclosing yourPHI todetermineeligibility fortreatmentora claimspayment.
  • Health CareOperationsincludescarryingoutadministrative,financial,legaland qualityimprovementactivitiesnecessary to run our businessandto supporteh corefunctionsoftreatmentand payment.Anexampleof thiswould bean internalquality assessmentreview.

Wemayalsocreateand distributede-identified healthinformation byremoving allreferences to individuallyidentifiableinformation.

Exceptasdescribed in thisNoticeorspecified bylaw,wewillnotuseor discloseyourPHI.Wewillusereasonableeffortstorequest,useanddisclosetheminimum amountofPHI.

All otherusesand disclosureswillbe madeonly withyourwritten authorization.Youmay revokesuchauthorizationatanytimebynotifying usinwriting.Wearerequired tohonorand abidebythatwritten requestexcepttotheextentthatwehavealreadytaken actionsrelyingon yourauthorization.

YOURRIGHTS

You havethefollowing rightswithrespectto yourPHI,which you canexerciseby presenting awritten requesttothePrivacyOfficer.

  • Therightto obtain,andwehavetheobligation toprovideto you,a papercopy ofthisnoticefromusatyour firstdateof service.
  • Therighttorequestrestrictionon certain usesand disclosuresofprotected health information,includingthoserelated todisclosures to family members,otherrelatives,closepersonalfriends, orany other person identified by you. Your requestmustbeinwritingand includewhatrestriction(s)youwantand towhom youwanttherestriction(s)toapply.Wewillreviewand grantreasonablerequests,butwearenotrequired toagreetoany restrictions.
  • TherighttoinspectandcopyyourPHI.You havethe righttoinspectand get acopy ofyourPHI foraslong aswemaintaintheinformation.Youmustputyourrequestinwriting.Wemay chargeyou forthecostsofcopying,mailing,orothersuppliesthatarenecessarytograntyourrequest.
  • TherighttorequestamendmenttoyourPHI.Ifyou feelthatyour PHI isincompleteor incorrect,youmayaskustoamend it. Yourrequestmustbeinwriting,and youmustincludea reason thatsupportsyourrequest.
  • Receivea list(an accounting) of disclosures.You havetherighttoreceivea listofthedisclosuresthatwehavemadeonyourPHI.Thelistwillnotincludedisclosuresthatwearenotrequired to track,suchasdisclosuresforthepurposes oftreatment,payment,orhealth careoperations; disclosureswhichyouhaveauthorized usto make;disclosuresmadedirectlyto youortofriend orfamilymembersinvolved inyourcare;ordisclosuresfornotification purposes.Yourrightto receivea listofdisclosuresmayalsobesubjectto otherexceptions,restrictions,and limitations. Your requestfora listofdisclosuresmustbemadeinwriting and statethetimeperiod forwhich you would likeustolistthedisclosures.Wewillnotincludedisclosuresmademorethansixyearspriortothedateofyourrequest.
  • Therighttoreasonablerequeststoreceiveconfidentialcommunicationsof protected health information.Youmay asktocommunicatewith you using alternativemeansor alternativelocations.Forexample,youmay askustocontactyouaboutmedicalrecordsonly in writingor ata differentaddressthan the oneinyour file.Yourrequestmustbemadeinwriting and statehowandwhenyouwould liketobecontacted.Youdonothaveto telluswhy youare makingtherequest,butwemayrequireyouto makespecialarrangementsforpaymentorothercommunications.Wewillreviewand grantreasonablerequests,butwearenotrequiredtoagreetoanyrestrictions.

You haverecourseifyou feelthatyourprivacyprotectionshavebeen violated.You havetherighttofilea formal,writtencomplaintwith us attheaddressbelow,orwith theDepartmentofHealth HumanServicesat:

Pleasecontactusformoreinformation:Formoreinformation aboutHIPAAor tofileacomplaint:Privacy Officer US Departmentof Health and Human Services

JillEllingson,MA,LMFTOfficeof CivilRights

BraveSoulCounseling Services,LLC200IndependenceAve.SW

P.O Box 489Washington,D.C.20201

Cottage Grove, MN 550161-877-696-6775

612-242-1224

Filing a complaintwillnotaffectthecareor servicesyou receiveatBraveSoulCounseling Services.

Effective 10-1-2012

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