YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about yourcare. You must submit a written request to Dr. Michael Ghormley, our Privacy Officer, in order to inspect, and/or copy your health information. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.

Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a Medical Record Amendment/Correction Form to Dr. Michael Ghormley. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:  

• We did not create, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the health information that we keep.
• You would not be permitted to inspect and copy.
• Is accurate and complete.

Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list of the disclosures that we made of medical information about you for purposesother than treatment, payment, or healthcare operations. To obtain this list, you must submit your request in writing to Dr. Michael Ghormley.It must state a time period,which may not be longer than sixyears and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically

Right to Request Restrictions You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved inyourcareorthe payment of it, such as a family member or friend. For example, you could ask that we not use or disclose information about a hospitalization you had.

As Required by Law We will disclose medical information about you when required to do so by federal, state, or local laws. For example, we may need to notify the appropriate government authority if we believe a client has been the victim of abuse, neglect, or domestic violence.

We are Not Required to Agree to Your Request If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the Request for Restrictions on Use/Disclosure of Medical Information to Dr. Michael Ghormley.

Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way, or at a certain location. For example, you may askthatwecontact you only at work or by mail. To request confidential communications, you may complete and submit the Request for Restrictions on Use/Disclosure of Medical Information And/Or Confidential Communication to Dr. Michael Ghormley. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact Dr. Michael Ghormley.

We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right - hand corner. You are entitled to a copy of the notice currently in effect.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services, Region VI, at 214-767-4056. To file a complaint with our office, contact Dr. Michael Ghormley, Privacy Officer, at 210-314-3476. You will not be penalized for filing a complaint.

 

Client Consent and Acknowledgement of Receipt of Privacy Notice

I understand that as part of the provision of services, Stonebridge Behavioral Health, PA creates and maintains health records and other information describing, among other things, my mental health history, symptoms, evaluations and test results, diagnoses, and treatment recommendations. I have been provided with a Notice of Privacy Practices that outlines a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices, and prior to implementation, will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, conducting or arranging for medical review, legal services, and auditing functions, etc and that the organization is not required to agree to the restrictions requested. By signing this form, I consent to the use and disclosure of Protected Health Information about me for the purpose of treatment recommendations, payment, and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent. This consent is given freely with the understanding that:

1. Any and all records, whether written or oral, or in an electronic format, are confidential and cannot be disclosed for reasons outside of treatment recommendations, payment, or health care operations without my prior written authorization, except as otherwise provided by law.
2. A photocopy, fax, or scan of this consent is as valid as the original.
3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment recommendation, payment, or health care operations, be restricted. I also understand that Stonebridge Behavioral Health, PA and I must agree: to any restriction in writing that I request on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions, in writing, on the use and disclosure of my Protected Health Information which have been previously agreed upon.
4. I understand that any court of competent jurisdiction can compel Stonebridge to produce my records, with or without my consent.
5. I also understand that Stonebridge at its discretion may notify emergency or law enforcement officials without written or verbal consent in the event that any patient appears to be at imminent risk for behaving in a way that could cause severe physical or emotional harm to self or others.
6. I understand further that Stonebridge must notify Child or Adult Protective Services if it receives any credible report of previously undocumented abuse or neglect of a child or elder.
7. I have been briefed on Stonebridge's Cancellation Policy and understand that if I do not arrive for my appointment at the scheduled time, there is a possibility that I will have to reschedule. I also understand that Stonebridge requires a minimum of one day's advance notice of my intent to cancel or reschedule an appointment. Furthermore, I understand that, after two missed appointments or late cancellations, I may not be able to reschedule without first receiving the approval from the treating clinician.