Because of concerns

412
The raised
brieferbyNotice
practitioners
of Privacythat
Practices
the NPP is too long for routine
use, too complex for most contacts, and will be confusing for many, DHHS has st
ated that a layered notice is acceptable. This means using a shorter version as a
top page of the longer version but it cannot substitute for the longer version a
nd must be written in plain language as well. The version below should be suitab
le and still fit on two sides of a page. The paragraph in capitals cannot be alt
eredyour
(On
Notice
THIS
andofletterhead)
NOTICE
must
Privacy
DESCRIBES
be displayed
Practices
HOW MEDICAL
prominently
BriefINFORMATION
Version
and theABOUT
top ofYOUtheMAYpage.
BE USED AND DISCLOSE
D ANDpractice
Our
commitment
HOW YOUisCAN
todedicated
GET ACCESS
your
privacy
to maintaining
TO THIS INFORMATION.
the privacy
PLEASE
of your
REVIEW
personal
IT CAREFULLY.
health in
formation as part of providing professional care. We also are required by law to
keep your information private. These laws are complicated, but we must give you
this important information. This pamphlet is a shorter version of the full, leg
ally required NPP and you may have a copy of this to read and refer to it for mo
re information. However, we cant cover all possible situations so please talk to
our Privacy Officer (see the end of this pamphlet) about any questions or proble
We will use the information about your health which we get from you or from othe
ms.
rs mainly to provide you with treatment, to arrange payment for our services, an
d for some other business activities which are called, in the law, health care o
perations. After you have read this NPP we will ask you to sign a Consent Form t
o let us use and share your information. If you do not consent and sign this for
m, we or
If
cannot
you want
treattoyou.
use or disclose (send, share, release) your information for
any other purposes we will discuss this with you and ask you to sign an Authori
zation
Of
course
formwetowill
allow
keepthis.
your health information private but there are some times
when theWhen
1.
lawsthere
require
is ausserious
to use threat
or sharetoit.
yourForhealth
example:
and safety or the health a
nd safety of another individual or the public. We will only share information wi
th a person
2.
3.
4.
There
areFor
Some
If
some
aWorkers
orlaw
lawsuits
organization
other
enforcement
Compensation
situations
and legal
who
official
or
isandcourt
like
able
similar
these
requires
toproceedings.
help
but
benefit
toprevent
which
do dont
so.or happen
programs.
reduce very
the threat.
often. They
Your
1.
are rights
described
You can
regarding
inasktheusyour
longer
to communicate
health
version
information
ofwith
theyou
NPP.about your health and related iss
ues in a particular way or at a certain place which is more private for you. For
example, you can ask us to call you at home, and not at work to schedule or can
cel an appointment.
2.
You have theWeright
willtotryaskourusbest
to limit
to dowhat
as you
we tell
ask. people involved in yo
ur care You
3.
or the
havepayment
the right
for to
yourlook
care,
at the
suchhealth
as family
information
members we
andhave
friends.
about you s
uch as your medical and billing records.* You can even get a copy of these recor
ds but we may charge you. Contact our Privacy Officer to arrange how to see your
4.records.IfSee
youbelow.
believe the information in your records is incorrect or missing i
mportant information, you can ask us to make some kinds of changes (called amend
ing) to your health information. You have to make this request in writing and se
nd it to our Privacy Officer. You must tell us the reasons you want to make the
5.
changes.
You have the right to a copy of this notice. If we change this NPP we wi
ll post the new version in our waiting area and you can always get a copy of the
6.NPP fromYouthehave
Privacy
the right
Officer.
to file a complaint if you believe your privacy right
s have been violated. You can file a complaint with our Privacy Officer and with
the Secretary of the Department of Health and Human Services. All complaints mu
st be in writing. Filing a complaint will not change the health care we provide
to you have
If
in anyanyway.
questions regarding this notice or our health information privac
y policies, please contact our Privacy Officer who is __________________________
_ andeffective
The
Also,
can may
you
be reached
date other
have
ofbythis
phone
rights
notice
atwhich
______________
is _______
are granted
___orto_______.
byyou
e-mail
by the
at laws
_______________
of our stat
e and these may be the same or different from the rights described above. I will
*be happyYoutoshould
discussmention
these the
situations
clientswith
access
you to
nowpsychotherapy
or as they arise.
notes if you have
decided to keep them.