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.

The medical practice of Ridgefield Psychiatry, LLC is strongly committed to protecting the confidentiality and security of your protected health information.  This notice describes the medical practice’s privacy practices.  Specifically, this notice describes:  1) how the practice will use or disclose medical information about you; 2) your rights with respect to your protected health information and how you may exercise your rights; and 3) the obligations the practice has regarding the use and disclosure of your protected health information.

The law requires that the practice:

• maintain the privacy of your protected health information;
• provide you with notice of our legal obligations and privacy practices with respect to your protected health information; and
• follow the terms of the notice that is currently in effect. 

“Protected health information” is information, including demographic information, that relates to your past, present or future physical or mental health or condition; or to the provision or payment of your health care; and that either identifies you or there is a reasonable basis could be used to identify you.

While we can use your protected health information without your consent for our own internal purposes related to treatment, payment and health care operations, federal and state law generally prohibits us from providing your patient information to others outside our organization without your consent, except to another provider for treatment purposes as long as the other provider is involved in your current treatment.  Examples of how we would use your protected health information are: 

For Treatment.  We may use or disclose your protected health information to others for the purpose of providing medical treatment and services to you.  For example, we may disclose your protected health information to other doctors, nurses, technicians, medical students or other personnel who are involved in treating and caring for you.  In order to provide health care services to you, such as x-rays, lab work, medication or therapy services, we may disclose your protected health information to others involved in providing these services.  We may also disclose your protected health information to family, friends or others involved in support services in order to provide continued care for you at home.

For Payment. We may use or disclose your protected health information to your health plan, your insurance company or other third party in order to obtain payment for the treatment or services provided to you.  For example, it may be necessary to provide your health plan with information about your condition and the treatment you received in order to establish the medical necessity for the treatment.  Also, many plans require that certain medical procedures be approved for payment in advance of providing the treatment or procedure.  Such use would be subject to your consent.

For Health Care Operations.  We may use or disclose your protected health information during the course of operating the office.  For example, we may review our patient’s medical information to ensure that quality treatment or services were provided to our patients.  Also in conducting training programs, your medical information may be given to students, trainees, or other practitioners being supervised to learn or improve skills.  We may also provide medical information to organizations accrediting our facility.  We may also provide medical information to health plans and other providers for their quality assessments and other limited purposes as long as you also have a relationship with that plan or provider.  Health care operations also include:

Appointment Reminder.  We may use and disclose your protected health information for the purpose of contacting you to remind you of an appointment you have for treatment or care.

Treatment Alternatives and Other Health-Related Benefits or Services.  We may use and disclose your protected health information to provide you with information about treatment alternatives or for the purpose of contacting you to alert you of other health-related benefits or services that may be of interest to you.    You may contact our Privacy Contact to request that these materials not be sent to you.

Persons Involved in Your Care or Payment of Your Care.  Your protected health information may be disclosed to a family member, a relative, a close friend, or someone identified by you who is involved in your care or in the payment of your care.  Also, your protected health information may be disclosed to disaster relief organizations for the purpose of helping to notify family and friends of your condition.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  YOU HAVE THE RIGHT TO RESTRICT OR LIMIT DISCLOSURE OF YOUR HEALTH INFORMATION TO OTHERS.  See “Rights to Restrict Use and Disclosure” under the section regarding your individual rights.

Public Health Activities.  Your protected health information may be disclosed to public health authorities authorized by law to collect and receive the information.  For instance, the information may be disclosed for the purpose of:

• preventing or controlling disease, injury or disability;
• reporting birth and death;
• reporting child abuse or neglect;
• reporting adverse reactions to medications or products;
• providing notification of product recalls;
• providing notification to individuals exposed to a communicable disease or at risk of contracting and spreading a disease or condition;
• evaluating work-related injuries or illness if employed by a health care provider.

Abuse, Neglect or Domestic Violence.  If it is reasonably believed that you are a victim of abuse, neglect or domestic violence, we are allowed to disclose your protected health information to government authorities, such as social or protective service agencies, that are authorized to receive reports on abuse, neglect and domestic violence.  Generally, we will only disclose information if you agree and to the extent required or authorized by law.  However, in the event that you are unable to agree, we may disclose medical information about you if, in our professional judgment, disclosure would prevent serious harm to you or to others, or if we receive assurance that the disclosed information will not be used against you and an immediate enforcement activity would be materially and adversely affected.

Health Oversight Activities.  We may disclose protected health information to agencies authorized by law to conduct health oversight activities.  These activities include audits; civil, administrative or criminal investigations or actions; inspections; licensure or disciplinary actions; or other activities appropriate for oversight of the health care system; government benefit programs for which health information is relevant to determine eligibility; and entities subject to government regulation to determine compliance with program standards.

Legal Disputes.  We may disclose your protected health information as part of a court or government agency proceeding.  Specifically, we may disclose your protected health information to respond to an order of a court or agency or to respond to a subpoena, discovery request or other lawful process as long as we are assured efforts were to obtain your authorization or to get an order from the court protecting the requested information from further use or disclosure.

Law Enforcement Officials.  We may disclose your protected health information to a law enforcement official in the following circumstances:

• to report certain types of wounds or physical injuries as required by law;
• to comply with various types of court orders, subpoenas, summons and legal demands;
• to assist in identifying or locating a suspect, fugitive, material witness or missing person;
• to report a death suspected to be caused by criminal conduct;
• to report a crime that occurred on our premises; and
• in an emergency situation, to report a crime, the location of the crime and the identity of the perpetrator of the crime.

Also, if you agree, we may disclose your protected health information to a law enforcement official if it concerns a suspected crime victim.  If you are unable to agree, or an emergency exists, we may disclose information if the information is necessary and would not be used against the victim, non-disclosure would cause a delay that would materially and adversely affect law enforcement activity, and using our professional judgment, disclosure would be in your best interest.

Coroners and medical examiners.  Your protected health information may be disclosed to coroners and medical examiners to identify a deceased person or to determine the cause of death or to conduct other duties authorized by law.

Funeral Directors.  We may disclose your protected health information to a funeral director so that they may carry out their duties and as required by law.

Organ and Tissue Donation.  We may disclose your protected health information to organ and tissue organizations for the purpose of obtaining donations and transplantations.

Prevention of Serious Threat to Health or Safety.  We may disclose your protected health information to prevent serious threat to the health and safety of a specific person or the general public.  Use and disclosure may only be made if necessary and to someone reasonably able to prevent or lessen the threat.

Military Activity and National Security.  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; 92) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation.  Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates.  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures.  Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the HIPAA regulations.

Except for the uses and disclosures described in this notice, use and disclosure will only be with your specific written authorization.  You will be able to revoke your authorization, in writing, at any time.  The authorization will not be revoked to the extent: 1) we have already relied and acted upon the authorization; or 2) the authorization was made as a condition to obtaining insurance coverage.

Unless otherwise permitted by law, we will not directly or indirectly receive remuneration in exchange for your protected health information unless we receive an authorization from you that includes a specification that your protected health information may be exchanged for remuneration.

We will also not disclose your health information to a third party for marketing purposes without your specific authorization to do so. We may, however, provide you with marketing materials in a face to face encounter without your authorization.  We may also communicate with you about treatment alternatives or other health related products and service that may be beneficial to you in relation to your treatment.

Lastly, most disclosures of psychotherapy notes require your authorization.  Unless otherwise permitted by law, we will not disclose psychotherapy notes unless we receive an authorization from you to specifically do so.

Right to Access.  You have the right to inspect and/or to obtain a copy of the health information pertaining to you, except for psychotherapy notes, information compiled in anticipation of legal action, and information that is subject to law that prohibits access to protected health information.  This includes the right to receive in an electronic format a copy of protected health information about you that is maintained as part of an electronic health record and to the electronic record transmitted directly to an entity or person designated by you.

To request access to your protected health information, please contact our Privacy Contact.  A reasonable fee may be charged to cover the costs of providing you with a copy of your protected health information not to exceed seventy-five cents per page.

We will try our best to provide your protected health information to you in the form or format requested by you if such form or format is readily available.  If it is not, the information will be provided in readable hard copy form or such other agreed upon form.  If you agree in advance, we may provide you with a summary or explanation of your protected health information.  You must also agree in advance to pay the fee for preparation of such summary or explanation.

You have the right to timely access to your protected health information.  Generally, you must be afforded the opportunity for visual inspection within 10 days or must be provided a copy within 10 days of your request.

We are permitted to deny access to your protected health information in a limited number of instances.  If we deny your request, you have the right to receive a timely, written denial explaining the reasons for the denial.  The written denial will also describe your right to review the denial and the procedures for filing a complaint.  Your denial will be reviewed by someone other than the individual involved in the denial.  In very limited circumstances, however, a denial to access is not reviewable.

Right to Amend. If you believe that health information contained in your medical and billing records maintained by us is incorrect or incomplete, you have the right to request that it be amended.  To request an amendment, please write to our Privacy Contact listed at the end of this notice and include the information you want changed and the reason for wanting this information changed.

We may deny your request for an amendment if your health information:

• was not created by us (unless the originator of the health information is no longer available to act on your request);
• is not part of the medical and billing records kept by us;
• is accurate and complete; or
• would not be available to you for inspection.

If we deny your request for amendment, we must provide you with a written denial explaining the reasons for the denial.  You have the right to submit a written statement of disagreement.  You may also file a complaint.  If we prepare a written rebuttal, you will be provided a copy of the rebuttal.

Right to an Accounting of Disclosures.  You have the right to know who has received your protected health information other than those disclosures for the purpose of treatment, payment, or health care operations or those pursuant to an authorization.  You may request that we provide you with a written statement or listing (referred to as an “accounting”) of disclosures of your protected health information that occurred during the six years before your request.  Additionally, if your records are maintained electronically your right to receive an accounting of disclosures, including disclosures for treatment, payment and healthcare operations made through an electronic health record, applies to disclosures made within three (3) years prior to your request.

The accounting will include:

• dates of disclosures;
• name of entities or persons who received your protected health information;
• a brief description of the protected health information disclosed;
• the purpose for the disclosure;
• a copy of your written authorization for the disclosure; and
• a copy of the request for disclosure;

To request an accounting, please write to our Privacy Contact and include the time frame for which you wish to receive an accounting.  The first accounting within a 12-month period will be provided free of charge.  We may charge a reasonable fee for additional accountings requested within the same 12-month period.  You will be advised of the charge before the accounting is prepared in order to provide you with an opportunity to withdraw or to modify your request.  In limited circumstances, certain disclosures are not included in the accounting.  If you have questions regarding which disclosures are not included, you may contact the person listed at the end of this memo for more information.

Right to Restrict Uses and Disclosure.  We understand that there may be situations in which you do not want your protected health information used by or disclosed to others.  You may request that the use and disclosure of your protected health information by us for treatment, payment or health care operations be restricted or limited.  You may also request that your protected health information not be disclosed to specific family members or friend involved in your care or the payment of your care.

We are not required to agree to the restriction or limitation.  If we do agree to the restriction or limitation, we will follow your wishes except to the extent that use or disclosure may be necessary to provide you emergency treatment.  If we must use or disclose protected health information in order to provide emergency treatment, we will request that the disclosed information not be further used or disclosed.

You may also request that we restrict disclosure to your health plan of your protected health information when your protected health information is related to an item or service for which you or someone on your behalf, other than the health plan, has paid us in full.  If you so request, when not otherwise required by law, we will not disclose such personal health information to your health plan as part of our payment or health care operations.

To request that a restriction or limitation be placed on your protected health information, please write to our Privacy Contact.  You may also write to this person to terminate a restriction or limitation.  We may terminate a restriction or limitation by informing you of such termination.  A termination will only be effective for protected health information created or received after you have been informed of the termination.

Right to be Notified in the Event of a Breach.   We are required to notify you in the event of a breach of your Unsecured Protected Health Information as soon as possible but no later than sixty (60) days after we discover the breach.  Unsecured Protected Health Information is information that is not deemed unreadable, unusable, indecipherable using technology, such as encryption, or other means specifically approved by the Secretary of the U.S. Department of Health and Human Services.  Any required notice shall include a description of the breach, the Unsecured Protected Health Information involved, steps you might take to protect yourself, a summary of out investigation and how to contact us for more information.

Right to Request Confidential Communications.  You may request, in writing, to receive confidential communications regarding your protected health information by an alternative method or at an alternative location.  For instance, if you wish to receive confidential communications by e-mail or at another address, such as at work or at a post office box, you may request it.  We will not ask you to explain your reason for the request and will accommodate reasonable requests.

To request confidential communications, please write to our Privacy Contact.

Right to Receive a Paper Copy of this Notice.  This notice is displayed in the medical practice. You may also receive this notice by e-mail if you so agree.  However, you always have the right to receive a paper copy this notice, even if you agreed to receive this notice electronically.  To request a paper copy of this notice, please contact our Privacy Contact.

If you believe that your protected health information was used or disclosed unlawfully, or that any of your rights with respect to your protected health information were violated, you may file a complaint with us or with you may file a complaint with the Office for Civil Rights (OCR). If complaining to us, your complaint should be in writing and sent to our Privacy Contact.  This is the same person who you may contact with questions regarding any of the information contained in this notice.  If you are complaining to OCR, you may contact the regional office at (212) 264-3313; (212) 264-2355 (TDD)
PLEASE BE ADVISED THAT NO ADVERSE ACTION WILL BE TAKEN AGAINST YOU FOR FILING A COMPLAINT.