1. Collection of Information From Clients When booking services, either by email, phone or if in the future we are able to provide online booking services, you should be aware that the following information will initially be collected: Client Name, Date of Birth, Address, Telephone Number, E-mail Address, Credit Card Information for Holding Appointment (credit card number, cardholder name, expiration date, cvc code, billing address), and if applicable, Insurance Information (name of health insurance company, member ID, group number, subscriber name, subscriber date of birth, subscriber address, subscriber telephone, client’s relationship to subscriber). You will also be required to agree to your provider’s specific cancellation fee and payment policy in order to book an initial appointment. You will have the option of submitting Intake Forms by email through the client portal, or you may print blank forms to bring the information in-person to your first appointment. Please note, sending e-mails in order to submit forms containing confidential or protected health information to us that we cannot guarantee the security of your own Internet Service Provider (ISP) or e-mail provider and you should proceed in doing so at your own risk.
2. Uses and Disclosure of PHI: Your PHI may be used and disclosed by your provider, owner and any others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of your provider’s practice. Following are examples of the types of uses and disclosures of your PHI that your provider’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by this practice. Treatment: We 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 another provider. For example, we would disclose PHI, as necessary, to other physicians who may be treating you or to whom we refer you for treatment. Payment from Insurers: Your PHI will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we 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. Please note by giving consent to bill services to your insurer, you are authorizing the insurer to request at any point the following information: your provider’s intake note and any subsequent Progress Notes, which can include the modalities and frequencies of treatment furnished, the results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date; counseling session start and stop times, and any medication prescription and monitoring. Health Care Operations: This practice may use or disclose, as needed, your PHI in order to support the business activities of our practice. We will share your protected health information with third party “business associates” that perform various activities (for example, billing services, administrative, legal, actuarial, accounting, consulting or data services) for your provider’s practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI. Please note that the individual provider operates an independent private practice, using Christina Beauregard LCSW, LLC as the business in which to handle some or all of the provider’s business activities, and as such you should review your provider’s policies. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object: This practice may use or disclose your PHI in the following situations without your authorization or providing you the opportunity to agree or object: This practice will use and disclose your PHI when required to do so by law. This practice’s use or disclosure will be Christina Beauregard LCSW, LLC @ 8237 Oak Street, New Orleans, LA 70118 • (504) 684-5373 • Christina.firstname.lastname@example.org • http://cbeauregardlcsw.weebly.com & made in compliance with the law and will be limited to the relevant requirements of the law. Examples of such required uses and disclosures are notifying public health authorities regarding public health activities including certain communicable diseases. Additionally, if required by law, or you agree, this practice would disclose your PHI to the appropriate government authority if it was thought that you have been the victim of abuse, neglect, or domestic violence or if you intend to harm yourself or another individual. This practice may disclose your PHI to a governmental agency or regulator with healthcare oversight responsibilities, for workers’ compensation or similar programs, in response to a request by a law enforcement official made via a court order, subpoena, warrant, summons or similar process, and to federal officials for national security and military activities authorized by law. If you are an inmate of a correctional institution or under the custody of a law enforcement official, this practice may release your PHI to the correctional institution or law enforcement officials as authorized by law. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization. Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization in writing at any time. If you revoke your authorization, this practice will no longer use or disclose PHI for the reasons covered by your written authorization. Please understand that this practice is unable to take back any disclosures already made with your authorization.
3. Your Rights: The following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights: Right to inspect and copy your PHI. This means you may inspect and obtain a copy of your PHI for so long as this practice maintains the PHI. You may obtain your medical record that contains medical and billing records and any other records that the practice or provider uses for making decisions about you. As permitted by federal or state law, this practice may charge you a reasonable copy fee for a copy of your records. Right to request a restriction of your PHI. This means you may ask this practice not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. Your request must state the specific restriction requested and to whom you want the restriction to apply. The provider and practice is not required to agree to a restriction that you may request. If there is agreement towards your requested restriction, the practice may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with the provider. Right to request to receive confidential communications from the practice by alternative means or at an alternative location. This practice will accommodate reasonable requests. This practice may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. The practice will not request an explanation from you as to the basis for the request. Please make this request in writing to your provider. Right to request that your provider amend your PHI. This means you may request an amendment of your PHI in a designated record set for so long as the practice maintains this information. In certain cases, the practice may deny your request for an amendment. If your request for amendment is denied, you have the right to file a statement of disagreement with the practice, who may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact the provider if you have questions about amending your medical record. Right to obtain a paper copy of this notice from the practice upon request, even if you have agreed to accept this notice electronically, through email.
4. Complaints: You may complain to this practice or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by this practice. You may file a complaint by notifying this practice of your complaint. We will not retaliate against you for filing a complaint. You may contact this practice for further information about the complaint process: Christina Beauregard LCSW, LLC @ T: 504-684-5373 or via email: email@example.com I have read and understand the above information.