This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
OUR PLEDGE TO PROTECT YOUR PRIVACY
AND TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)
Hope Merchant Counseling, LLC (herein, “HMC”), including its providers, supervisors, subcontractors, and staff, know that health information about you is personal, and we are committed to protecting the privacy of your information. By law we are required to ensure that your PHI is kept private. The PHI constitutes information created or noted by HMC that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of mental health care services to you, or the payment for such care. HMC is required to provide you with this Notice about our privacy procedures. This Notice must explain when, why, and how we would use and/or disclose your PHI.
HMC may use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Use of PHI means when we share, apply, utilize, examine, or analyze information within the practice; PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we will always be legally required to follow the privacy practices described in this Notice.
HMC reserves the right to change the privacy practices and the terms of this Notice at any time as permitted by law. Any changes will apply to PHI already on file with HMC. Before HMC makes important changes to the privacy practices and policies, we will change this Notice and make the new Notice available in on our website and upon request.
Uses and Disclosures That Do Not Require Your Prior Written Consent.
HMC may use and disclose your PHI without your consent for the following reasons:
- For treatment. We can use your PHI within the practice to provide you with mental health treatment, including discussing or sharing your PHI with and between providers, supervisors, contractors, or staff involved in your care. Disclosures for treatment purposes are not limited to the minimum necessary standard. Treatment refers to activities in which HMC provides, coordinates, or manages your mental health care or other services related to your mental health care. This includes discussions between your therapist and their supervisor or other staff to ensure quality of services. Examples include the content of counseling sessions, results of psychological testing and assessment, and information provided via the intake process.
- To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: We might send your PHI to any person responsible for payment if other than yourself. We could also provide your PHI to Business Associates, such as billing companies, credit card processing companies, collection agencies, or others that process health care claims or payments for the office.
- For health care operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as administrative, record-keeping, accounting/auditing, and/or legal or financial services. At times it may be necessary for us to provide certain of your PHI to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
- Emergency disclosures. If you are unavailable, incapacitated, or facing an emergency medical, mental health, or disaster situation and we determine that a limited disclosure may be in your best interest, we may share limited PHI with emergency contact individuals without your approval.
- Appointments and Services. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your PHI from us by alternative means or at alternative locations.
- By Law or Other Governmental, Legal, or Military Agency as required by law. We may release your Protected Health Information for any purpose required by law or mandate; including, but not limited to, public health investigations, suspected child, elder, or dependent adult abuse or neglect, worker’s comp claims, etc. If a use or disclosure of your Protected Health Information under the HIPAA Privacy Ruling is prohibited or otherwise limited by another State or Federal law applying to the information, we are required to follow the more stringent law.
Certain Uses and Disclosures Require You to Have the Opportunity to Agree or Object.
- For Notification and Other Purposes. HMC may rely on an individual’s informal permission to disclose to the individual’s family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person’s involvement in the individual’s care or payment for care. Example: If you bring a friend or family member to an appointment, it is permissible to discuss your condition, plan of care, and other matters typically discussed in such an appointment with the friend or family member present. Your consent is assumed if you invited this person to be involved in your care or payment for care.
Uses and Disclosures Requiring Authorization
In any other situation not described above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures of your PHI by us.
- Psychotherapy Notes. A separate and specific authorization is required before we release your Psychotherapy Notes (if any). Psychotherapy Notes are notes kept regarding specific conversations or impressions during a private, group, joint or family counseling session. These notes are are kept separate from the rest of your mental health record. These notes are given a greater degree of protections than PHI and are different from your session notes documenting appointments, type of treatment, modalities of care, results of tests or assessments, and any summary of your diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. In some cases, it is not appropriate for Psychotherapy Notes to be disclosed to anyone and in such a case we may decline to disclose them.
YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI
- The Right to Request Restrictions on certain uses and disclosures of your protected health information. However, HMC is not required to agree to a restriction you request.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. HMC will comply with all reasonable requests.
- Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. HMC may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, HMC will discuss with you the details of the request and denial process.
- Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. HMC may deny your request. On your request, HMC will discuss with you the details of the amendment process.
- Right to an Accounting – You generally have the right to receive an accounting of non-authorized disclosures of PHI. On your request, HMC will discuss with you the details of the accounting process.
- Right to a Paper Copy – You have the right to obtain a paper copy of the notice from HMC upon request, even if you have agreed to receive the notice electronically.
If you are concerned that HMC has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact the Privacy Officer, Jean Ricks-Ayer, at firstname.lastname@example.org. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
Notification of Breaches
The acquisition, access, use or disclosure of PHI in violation of the privacy rules is presumed to be a reportable breach unless HMC demonstrates that there is a low probability that the [PHI] has been compromised based on a risk assessment of at least the following factors:
- The nature and extent of the [PHI] involved;
- The unauthorized person who used the [PHI] or to whom the disclosure was made;
- Whether the [PHI] was actually acquired or viewed; and
- The extent to which the risk to the [PHI] has been mitigated.
In the case of a breach, HMC is required to notify each affected individual whose unsecured PHI has been compromised based on the risk assessment.
Changes to the Terms of This Agreement:
Hope Merchant Counseling, LLC can change the terms of this notice, and the changes will apply to all information HMC has about you. Any updates to this notice will be available upon request and on the HMC website.
Effective Date: September 1, 2021
Right to Receive a Good Faith Estimate of Expected Charges
Right to Receive a Good Faith Estimate of Expected Charges
Under the federal No Surprises Act, you have the right to receive a Good Faith
Estimate for the total expected cost of any non-emergency healthcare services,
including psychotherapy services.
Notice to clients and prospective clients:
Under the law, health care providers need to give clients who don’t have
insurance or who are not using insurance an estimate of the expected charges for
medical services, including psychotherapy services.
You can ask your health care provider, and any other provider you choose, for a
Good Faith Estimate before you schedule a service, or at any time during
If you receive a bill that is at least $400 more than your Good Faith Estimate, you
can dispute the bill. Make sure to save a copy or picture of your Good Faith
For questions or more information about your right to a Good Faith Estimate, or
how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises.
Effective January 1, 2022