Our website address is: http://doritlcsw.com. This site belongs to Circle of Life Counseling, LLC, which is managed by Dorith Prutchi, MSS, LCSW – Licensed Clinical Social Worker
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your mental and physical health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the National Association of Social Workers (NASW) Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of this Notice and any revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or members of our treatment team. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the services provided to you. This will only be done with your authorization which we request at the time of intake. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. We will limit the information disclosed to that allowed by applicable law or pursuant to your authorization.
For Health Care Operations. We may use or disclose your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing, collection or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. We will disclose the minimum amount of PHI necessary for these purposes. For training or teaching purposes PHI will be disclosed only with your authorization. We may use your PHI to schedule appointments with you, which may be by text message if you consent to such communications.
Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA, applicable law and NASW ethical standards, without an authorization.
Abuse or Neglect; Domestic Violence. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect or domestic violence.
Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written authorization), court order, administrative order or similar process.
Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate.
Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm.
Family or Friend Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent, which may be oral or written, or as necessary to prevent serious harm. If, due to your incapacity or an emergency, you are unable to agree or object to a use or disclosure, we may exercise our professional judgment in order to determine whether such use or disclosure would be in your best interests. Where we would disclose information to a family member or a close friend, we would disclose only that information we believe is directly relevant to his or her involvement with your care or payment related to your care. We will also disclose your PHI in order to notify or assist with notifying such persons of your location, general condition or death.
Health Oversight. If required by law, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written authorization), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws or the need to prevent serious harm.
Public Health. If required by law, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability or, if directed by a public health authority, to a government agency that is collaborating with that public health authority.
Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat, and as required by law.
Third Party Reimbursement of Your Treatment Expenses. We may use or disclose your PHI to the extent necessary to comply with state law for workers’ compensation or other similar programs, for example, to provide reports required for third-party reimbursement of client treatment expenses regarding a work-related injury you received.
Inmates. If you are an inmate in a correctional institution or otherwise in the custody of law enforcement, we may disclose your PHI to the correctional institution or law enforcement official(s) where necessary: (i) for the institution to provide health care; (ii) to protect your health and safety or the health and safety of others; or (iii) for the safety and security of the correctional institution.
Research. PHI may only be disclosed after a special approval process or with your authorization.
As Required by Law. We may use or disclose your PHI in any other circumstances other than those listed above where we would be required by state or federal law or regulation to do so, such as disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices. Generally, we will need your written authorization prior to disclosing: (i) HIV/AIDS information; (ii) sexually transmitted disease information; (iii) substance abuse information; and (iv) genetic information. In circumstances where more than one family member is receiving services, each family member receiving services must agree to authorize a disclosure.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at 1451 Chews Landing, Suite 204, Laurel Springs, NJ 08021. If you believe we have violated any of these rights, you have the right to file a written complaint with our Privacy Officer or with the Secretary of Health & Human Services, 200 Independence Ave., S.W., Washington, D.C. 20201 or by calling (20) 619-0257. We will not retaliate against you for filing a complaint.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set” within 30 days of your request. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care and are maintained as part of your record under state law. Your right to inspect and/or copy such PHI will be restricted only in those situations where there is compelling evidence that access would adversely affect your health or welfare, in which case we may provide a summary of the PHI accompanied by an explanation of the reasons for withholding any information. We may charge a reasonable, cost-based fee for copies, as allowed under applicable law. If your records are maintained electronically (which we currently do not do), you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. We will respond within 30 days of your request. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We will respond within 30 days of your request and may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
- Breach Notification. If there is a breach of unsecured PHI concerning you, we will notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
The effective date of this Notice is April 1, 2019.
What personal data we collect through the Contact Form and why we collect it
We collect the data shown in the contact form, and also the visitor’s IP address and browser user agent string to help spam detection. The information that you enter on the contact form is sent via plain-text (unencrypted) e-mail to Dorith Prutchi LCSW. No clinical or other information deemed confidential should be entered through the Contact Form.
