HIPPA NOTICE OF PRIVACY PRACTICE
THIS NOTICE CONTAINS INFORMATION CONCERNING HOW CONFIDENTIAL MENTAL HEALTH TREATMENT INFORMATION CONCERNING YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND LET US KNOW ANY QUESTIONS THAT YOU MAY HAVE CONCERNING THIS NOTICE.
I. MY PLEDGE REGARDING YOUR HEALTH INFORMATION:
Tikkun Counseling Group, LLC understands that health information about you and your health care is personal. Tikkun Counseling Group, LLC is committed to protecting health information about you. Tikkun Counseling Group, LLC creates a record of the care and services you receive from the company. Tikkun Counseling Group, LLC needs this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which Tikkun Counseling Group, LLC may use and disclose health information about you. Tikkun Counseling Group, LLC also describes your rights to the health information Tikkun Counseling Group, LLC keeps about you, and describe certain obligations Tikkun Counseling Group, LLC have regarding the use and disclosure of your health information.
II. HOW TIKKUN COUNSELING, LLC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
Without specific written authorization, Tikkun Counseling Group, LLC is permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.
1. Treatment: treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
2. Payment: Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.
3. Health Care Operations: these include the business aspects of running our clinics, such as conduction quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.
4. Contacting You: Tikkun Counseling Group, LLC may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.
5. Required by Law: Tikkun Counseling Group, LLC might disclose protected health information when required by law. This includes, but is not limited to: (a) reporting child abuse or neglect to the Department of Human Services or to law enforcement; (b) when court ordered to release information; (c) when there is a legal duty to warn of a threat that a client has made of imminent physical violence, health care professionals are required to notify the potential victim of such a threat, and report it to law enforcement; (d) when a client is imminently dangerous to herself/himself or to others, or is gravely disabled, health care professionals may have a duty to hospitalize the client in order to obtain a 72-hour evaluation of the client; and (e) when required to report a threat to the national security of the United States.
6. Health Oversight Activities: Your confidential, protected health information may be disclosed to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, regulatory programs or determining compliance with program standards.
7. Crimes on my premises or that Tikkun Counseling Group, LLC observed: Crimes that observed by the company, or that are directed toward staff, or occur on my premises will be reported to law enforcement.
8. Business Associates: Confidential health care information concerning you provided to insurers or to plans for purposes of payment for services that you receive may be disclosed to business associates. For example, some administrative, clinical, quality assurance, billing, legal, auditing and practice management services may be provided by contracting with outside entities to perform those services. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
9. Research. Protected health information concerning you may be used with your permission for research purposes if the relevant provisions of the Federal HIPPAA Privacy Regulations are followed.
10. Involuntary Clients: Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed in compliance with Colorado law.
11. Family Members: Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
12. Emergencies: In life threatening emergencies Tikkun Counseling Group, LLC will disclose information necessary to avoid serious harm or death.
13. Workers’ compensation purposes: Although my preference is to obtain an Authorization from you, Tikkun Counseling Group, LLC may provide your PHI in order to comply with workers’ compensation laws.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION
1. Psychotherapy Notes: Tikkun Counseling Group, LLC does keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For Tikkun Counseling Group, LLC use in treating you.
b. For Tikkun Counseling Group, LLC use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes: As a psychotherapist, Tikkun Counseling Group, LLC will not use or disclose your PHI for marketing purposes.
3. Sale of PHI: As a psychotherapist, Tikkun Counseling Group, LLC will not sell your PHI in the regular course of my business.
IV. YOUR RIGHTS AS A CLIENT WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION
1. Access to Protected Health Information: You have the right to receive a summary of confidential health information concerning you concerning mental health services needed or provided to you. There are some limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask Tikkun Counseling Group, LLC staff for the appropriate request form.
2. Amendment of Your Record: You have the right to request that Tikkun Counseling Group, LLC amend your protected health information. Tikkun Counseling Group, LLC is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you.
3. Accounting of Disclosures: You have the right to receive an accounting of certain disclosures Tikkun Counseling Group, LLC has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed Authorization, or disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an accounting.
4. Additional Restrictions: You have the right to request additional restrictions on the use or disclosure of your health information. I do not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request.
5. Alternative Means of Receiving Confidential Communications: You have the right to request that you receive communications of protected health information from Tikkun Counseling Group, LLC by alternative means or at alternative locations. For example, if you do not want Tikkun Counseling Group, LLC to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process.
6. Copy of this Notice: You have a right to obtain another copy of this Notice upon request.
You may submit a written request for any of the above mentioned to the person you are working:
Joanna M. Kipnis, LCSW
Ari Kipnis, LCSW
V. NOTICE REGARDING USE OF TECHNOLOGY
1. Communication via unencrypted e-mail, Skype, Facetime, WhatsApp, Signal or other similar videoconferencing technology may not be confidential. Please let Tikkun Counseling Group, LLC know if you do not want the company to use these means of communication. For online counseling and coaching, Tikkun Counseling Group, LLC uses ZOOM, which is a HIPPA compliant telemedicine online platform. Tikkun Counseling Group, LLC will only use forms of communication that you agree to use.
2. Storage of Health Care Information: Health care records and information maintained on the cloud may not be confidential, depending on the number of servers involved. Tikkun uses a HIPPA compliant electronic medical record system, Simple Practice.
3. Voicemail. Telephone messages left through voicemail may not be confidential, if they may be accessed by individuals other than the client. Please let Tikkun Counseling Group, LLC know if you do not want the company to use voicemail in contacting you.
4. Facsimile Communication. The submission of health care information or records by fax may not be confidential, and may lead to a disclosure of confidential information to third parties if the wrong fax number is used to send the information.
5. Communication by U.S. Mail. Communication of information by U.S. mail may lead to disclosure of private information to third parties, depending on who may open the mail. Please let Tikkun Counseling Group, LLC know if you do not want the company to send you correspondence, billing invoices, or other information through the U.S. mail.
IV. ADDITIONAL INFORMATION
A. Privacy Laws: Tikkun Counseling Group, LLC required by State and Federal law to maintain the privacy of protected health information. In addition, Tikkun Counseling Group, LLC required by law to provide clients with notice of its legal duties and privacy practices with respect to protected health information. That is the purpose of this Notice.
B. Terms of the Notice and Changes to the Notice: Tikkun Counseling Group, LLC required to abide by the terms of this Notice, or any amended Notice that may follow. I reserve the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted in Tikkun Counseling Group, LLC service delivery sites and will be available upon request.
C. Complaints Regarding Privacy Rights: If you believe I have violated your privacy rights, you have the right to submit a written complaint to the United States Secretary of Health and Human Services by sending your complaint to:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 515F, HHH Bldg.
Washington, D.C. 20201.
It the policy of Tikkun Counseling Group, LLC that there will be no retaliation for your filing of such complaints.
D. Additional Information. If you desire additional information about your privacy rights while working with Tikkun Counseling Group, LLC, please ask us any questions that you may have.
V. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS
A. The confidentiality of alcohol and drug abuse patient records maintained by Tikkun Counseling Group LLC is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:
1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
B. Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
C. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Disclosure may be made concerning any threat made by a client to commit imminent physical violence against another person to the potential victim who has been threatened and to law enforcement.
D. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
Any dispute that may arise under this agreement will be governed under Colorado Law.