Notice of Privacy Practices
Amanda Birdsall Counseling PLLC
Amanda Birdsall, LMHC
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your health record contains personal information about you and your health and is protected by the Health Insurance Portability and Accountability Act (HIPAA) as well as state laws. Protected Health Information (PHI) is information about you, including demographic information that may identify you and relates to your past, present, or future conditions and related health care services.
YOUR RIGHTS - When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities. You have the right to:
• Get an electronic or paper copy of your medical record – You may request a copy of your medical record and other health information I have about you. A response to your request will be made within 15 working days. I may charge a reasonable fee for the preparation, copying or sending of requested records. I will discuss any fees with you at the time of a request.
• Correct your medical record - You can ask me to correct health information that you think is incorrect or incomplete. I may say no at my clinical discretion but will tell you why. A response to your request will be made within 10 working days.
• Request confidential communication - You can ask me to contact you in a specific way (for example, home or cell phone) or to send mail to a different address. I will say “yes” to all reasonable requests.
• Ask me to limit the information I share - You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.
• Get a list of those with whom I have shared your information - You can ask for a list (accounting) of the times I have shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I will provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
• Choose someone to act for you - If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before I take any action.
• File a complaint if you believe your privacy rights have been violated – You can complain by contacting me at email@example.com. You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.
YOUR CHOICES - For certain health information, you can make choices about what I share. If you have a clear preference for how I share your information in the situations described below, tell me what you want me to do, and I will follow your instructions. In these cases, you have the right and choice to tell me to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation If you are not able to tell me your preference, for example, if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when necessary to lessen a serious and imminent threat to health or safety.
In the following cases, I never share your information unless you give me written permission:
• Marketing purposes
• Most sharing of psychotherapy notes
MY USES AND DISCLOSURES - I typically use or share your health information in the following ways:
• To Treat You - I can use your health information and share it with other professionals who are treating you. Example: If you are seeing me through an organization, I may consult with another provider who is also treating you within that organization to coordinate care. I may also share the minimum necessary with other providers or individuals involved in your care in the event of an emergency.
• To Run my business - I can use and share your health information to run my practice, improve your care, and contact you when necessary. Example: I may share your PHI with third parties that perform various business activities (e.g., billing and electronic records services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI.
• To Bill for your services - I can use and share your health information to bill and get payment from health plans or other entities. Example: I can give information about you to your health insurance plan so it will pay for your services, including determining eligibility or coverage under a plan and adjudicating claims; risk adjustments; billing and collection activities; reviewing health care services for medical necessity, coverage, justification of charges, and the like. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
HOW ELSE CAN I USE OR SHARE YOUR HEALTH INFORMATION? I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I must meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues - I can share health information about you for certain situations, such as:
• Helping with product recalls
• Preventing disease
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• Health research
Compliance with the law - I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law. Per WA state law, I may choose, or be required, to share your information in the following situations:
• If you give me written permission to release information to another party (such as a doctor or other health care provider for coordination of care, or an emergency contact)
• In the case of your death or disability, your personal representative may provide me with written permission to share information
• If you waive confidentiality by bringing legal action against me
• In response to a valid subpoena from a court or from the secretary of the Washington State Department of Health for records related to a complaint or report under RCW 18.130.050
• As required under state law to protect children and vulnerable adults from abuse and neglect
• If I reasonably believe that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of any other person
• As required under RCW 71.05.217 (regarding certain waivers of privilege in cases of legal proceedings related to grave disability or potential harm to self or others)
• If you reveal contemplation or commission of a crime or harmful act
• If I have any other legal duty, obligation, or right to report
Work with a medical examiner or funeral director - I can share health information with a coroner, medical examiner, or funeral director when an individual dies
To address workers’ compensation, law enforcement, and other government requests - I can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
To respond to lawsuits and legal actions - I can share health information about you in response to a court or administrative order, or in response to a subpoena.
• I am required by law to maintain the privacy and security of your protected health information.
• I must follow the practices described in this notice and give you a copy of it.
• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time by letting me know in writing. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Effective Date and Changes to the Terms of this Notice: This Notice of Privacy Practices is effective as of January 8, 2022. I reserve the right to change the terms of this notice at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. The new notice will be available on my website. I will send you an electronic copy or a paper copy by mail upon your request.
For More Information or to Report an Issue: I am my own Privacy Officer. If you have questions about this notice, or would like additional information, you may contact me at:425-285-8979 or firstname.lastname@example.org. If you believe that your rights have been violated, you have the right to file a complaint in writing with me, or with the Department of Health and Human Services, which requires all complaints must be in writing, describe the violation, and be filed within 180 days of when you learned of the violation. The Department of Health and Human Services requires that complaints be filed by mail, e-mail, or via the OCR Complaint Portal (https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf). I will not retaliate against you for filing a complaint. U.S. Department of Health and Human Services Centralized Case Management Operations U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F HHH Bldg. Washington, D.C. 20201 Email: OCRComplaint@hhs.gov. Portal: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Prior to working together, you will be asked to sign this Notice of Privacy Practices in order to acknowledge that you received it. The law does not require you to sign it, however not signing does not prevent me from using your information for any of the above purposes, and I am required to keep record of refusal to sign.