Notice of Privacy Practices (HIPAA ACT)

This notice describes how medical/mental health information about you may be used or disclosed and how you can get access to this information. Please review it carefully. ARTISTIC LEGENDS ABA must maintain the privacy of your health information and to provide you with this notice. You will be asked to sign a Release of Information Form. Once you have signed the Release of Information Form, ARTISTIC LEGENDS ABA employees may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, obtaining payment, or to conduct healthcare operations. For example, to receive payment for our services, ARTISTIC LEGENDS ABA must provide information to the funding source being used.

Other permitted and required uses and disclosures that may be made without your consent, authorization, or opportunity to object include: Abuse or Neglect: If any ARTISTIC LEGENDS ABA member suspects abuse or neglect of a child or elder, he/she is mandated to make a report to the appropriate public authorities. Danger: If an ARTISTIC LEGENDS ABA employee suspects that you are in imminent danger of harming yourself or someone else, he/she is mandated to make a report of the person at risk to the public authorities. Legal Proceedings: ARTISTIC LEGENDS ABA employees may disclose Personal Health Information (PHI) in response to a court order or subpoena or certain other legal proceedings. You have the following rights regarding PHI that ARTISTIC LEGENDS ABA maintains about you: Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your care. Usually, this includes demographic and billing records but does not include case notes. To inspect and receive copies of information, you must submit a request in writing. If you request a copy of the information, ARTISTIC LEGENDS ABA may charge a fee for the cost of copying, mailing, or other supplies associated with your request. ARTISTIC LEGENDS ABA must respond to your request within fifteen (15) days of receipt. Right to Amend: If you feel that the PHI about you is incorrect or incomplete, you may ask ARTISTIC LEGENDS ABA to amend the information. You have a right to request an amendment for as long as ARTISTIC LEGENDS ABA keeps the information. Your request for amendment must be in writing and must provide a reason supporting your request.

Right to an Accounting of Disclosures: You have the right to request an Accounting of Disclosures regarding information that ARTISTIC LEGENDS ABA employees have made about you. You must submit your request in writing to the above address. Your request must state a period for the disclosures, which may not be longer than six (6) years and may not include dates before 07/01/2020.

Right to Request Restrictions on Uses and Disclosures: You may request that disclosure of confidential information be limited. If ARTISTIC LEGENDS ABA is unable to agree to that restriction, we can discuss other options, such as referral to another counselor.

Right to Limit Reception of Confidential Information: For example, you may request that ARTISTIC LEGENDS ABA employees only contact you at a certain telephone number or address. You do not have to give a reason for your request.

Right to a Paper Copy of this Notice of Privacy Practices: You have a right to a paper copy of this signed notice.

Other uses and disclosures of PHI, and any disclosure of Case Notes, will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time from future use. This notice may be amended as needed to comply with federal, state, and professional requirements.

Notice of Privacy Practices Receipt/HIPAA Act Form

,have read and received a copy of the Notice of

Privacy Practices (HIPAA ACT) from the employees of ARTISTIC LEGENDS ABA.