Notice of Privacy Practices

This notice describes how your medical records and related personal information may be used and disclosed by Heartland Psychotherapy LLC and how you are able to access this information. Please review it carefully. This consent form applies to all providers and all locations that I may receive care at through Heartland Psychotherapy LLC.

Heartland Psychotherapy LLC, is required by law to maintain the privacy of your protected health information (PHI). This document provides you with notice of your privacy rights and the legal duties and privacy practices of your practitioners and Heartland Psychotherapy LLC with respect to your PHI. All terms of this notice regarding your PHI will be followed, unless terms are amended or added, to remain in accordance with federal and state law. If this notice changes, you will receive a copy of the revised notice via U.S. mail, to the last address you have provided for this communication purpose, or via email if you have indicated you prefer to receive electronic communication. At any time, you may request a paper copy of this notice, or an amended version, and one will be provided to you.

Understanding Your Protected Health Information

Protected health information is any identifiable patient information that contains: 

1. Any      information that concerns your health and medical status or personal      identifying information;
2. Any      information about medical or psychiatric care that has been, is being, or      will be delivered to you;
3. Financial      information regarding payment for your medical visits and procedures and      insurance information; and 
4. Any information about genetic testing, results, or information about you or your family members; a request for genetic services; clinical research participation that is related to genetics; or symptoms and/or diagnosis of a genetic disease or condition of either you or your family member(s). 

The purpose of creating and storing your medical record is to document your hospital and clinic visits and communications between you and your health care providers. This process allows Heartland Psychotherapy LLC to provide informed and quality care to our patients and to remain in compliance with all applicable federal and state laws. Your medical record will contain, among other things, examinations and test or lab results, diagnoses, treatments, visit notes, prescription orders, and a plan for future care or treatment. 

Your Health Information Rights

Although your health record is the physical property of Heartland Psychotherapy LLC, the information contained in it belongs to you. You have the following privacy rights:

1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or health care operations.

· It is important for you to know that if agreeing to certain requests would negatively affect your care, Heartland Psychotherapy LLC reserves the right to deny your request. 

· If you pay out-of-pocket, in full, for a health care or service cost, you may request that Heartland Psychotherapy LLC not share that information or the information related to your service with your health insurer, and Heartland Psychotherapy LLC will abide, provided there is not a law that requires that information to be shared. 

2. The right to ask Heartland Psychotherapy LLC to correct health information that you believe to be incorrect or incomplete. Please ask us how to do this. Heartland Psychotherapy LLC reserves the right to deny your request, and you will be given notice in writing within 60 days as to why the request was denied. Additionally, if your request is denied, you can speak with your health care provider and request documentation of your request to be included in your health record, along with the denial, and for those documents to be included in any future disclosures of your PHI. Your request for amendment will automatically be denied if the documentation was created by an outside agency.

3. The right to ask us to contact you confidentially. You may specify to us the means in which you would prefer communications (via telephone, U.S. mail, email, etc.), and Heartland Psychotherapy LLC will do its best to accommodate this request, within reason. 

4. The right to request restrictions on the use and disclosure of your name, location of where you receive treatment or care, your health or medical status, diagnoses, or any other identifying information. You have the right to limit:

• disclosure      to your family and friends;
• certain      disclosures to those involved in your care, unless it would negatively      affect the quality of the care you would receive; or
• in the event of a disaster relief situation. 

5. The right to get a list (an “accounting”) of those with whom we’ve shared your health information and why. This information is available to you for up to six years prior to the date you request this list. Not included in this list is:

• Disclosures you requested Heartland Psychotherapy LLC to make to specific individuals or entities. 
• Disclosures done for purposes of payment.
• Disclosures that are industry practice for health care operations.
• Disclosures that are mandatory according to federal and state law, or for the purposes of maintaining our license with DHS or the Department of Health. 

One accounting will be available to you per year at no cost. If you require more than one list in a 12-month span, you may be required to pay a reasonable fee for it. 

6. The right to file a complaint if you feel your rights have been violated and Heartland Psychotherapy LLC will not retaliate against you if you file a claim. 

You can 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/. 

7. The right to inspect and copy your PHI, in the presence of a Heartland Psychotherapy LLC staff person, unless in the case of psychotherapy notes, if your clinician or treatment team has determined that disclosure to you of the information contained would be detrimental to your physical or mental health, or it is likely to cause you to inflict self-harm or harm to another. 

You may request copies of your PHI by submitting a written request or filling out a release of information form that details your request. Heartland Psychotherapy LLC will provide requested documents within a reasonable period, no more than 10 business days. There may be a fee for each page copied. 

8. The right to rescind a release of information or authorization to release your PHI to an outside entity or agency. If the information has already been shared with your permission, we cannot take the information back, however, if you have given permission and change your mind, you can rescind the release of information at any time. You may do this by submitting your request in writing. 

Heartland Psychotherapy LLC’s Responsibilities regarding your PHI:

• It is our duty to keep your health information secure, private, and protected. 
• It is our duty to notify you if there has been a breach of your health information. 
• We will follow the responsibilities and practices laid out in this notice and remain up to date with changes in federal or state law to remain in compliance. 
• We will abide by your requests regarding your PHI, within reason, and according to applicable federal and state law. 
• We will never share your information without your written consent for marketing purposes or the sale of your information. 
• We will make all attempts to ensure your PHI is a thorough and complete representation of the services and treatments you receive with Heartland Psychotherapy LLC.

How Heartland Psychotherapy LLC may use or disclose your PHI, with your consent (please note that releases of information or written consent that is signed and dated is generally only valid for a period of one year, or less if specified):

• For the purposes of your treatment, payment for services, and the general operations of Heartland Psychotherapy LLC.  
• When you have requested your medical record, or portions of your medical record, be released to another agency/entity. 
• When organ and tissue donation or organ procurement organizations request it. 
• For health, medical, or scientific research, provided you do not object to it. If you object, your health information will not be released. 

If you do not object and portions of your health record are released, you may request, and we will provide, information on to whom the health record was released to and the date it was released. 

In most cases, Heartland Psychotherapy LLC will not connect your name to health records released for research purposes.  

Heartland Psychotherapy LLC may share your personal information with public health or other authorized agencies without your consent (under federal and state law) when:

• The disclosure is to a related entity that is affiliated with Heartland Psychotherapy LLC and it is related to your treatment.
• The disclosure is to provide health care services in the event of a medical emergency or disaster relief situation. 
• There is a substantial barrier to communicating with you and Heartland Psychotherapy LLC's medical or clinical staff believes you intend for us to provide care to you. 
• Health care services are provided to you as an inmate.
• Heartland Psychotherapy LLC is required by law to treat you, and we are unable to obtain your consent, despite attempting to do so. 
• Heartland Psychotherapy LLC is complying with certain government functions such as      military, national security, correctional facilities, and presidential protective services. 
• It is necessary to protect or reduce a serious threat to someone’s health or safety. You will be informed of this disclosure, unless informing you would further put that person’s safety or health at risk.
• Suspected abuse or neglect of a child or vulnerable adult is reported. 
• Reporting product recalls.
• Preventing or controlling diseases.
• Reporting adverse reactions to medications.
• It is a part of Heartland Psychotherapy LLC's oversight activities, such as audits, inspections, or investigations from a government agency. 
• It is a part of managing our operations, such as with business partners that we do work with but are not our employees or affiliates. These business partners are required by law to keep your information secure and protected. 
• It is required for workers’ compensation claims.
• It is necessary to work with a medical examiner or coroner. 
• A      public health authority is collecting information regarding vital life events, such as birth or death.
• Legal actions require it, such as a court order, grand jury subpoena, warrant,      or other legal process or for law enforcement purposes. 
• To defend Heartland Psychotherapy LLC in a legal action or related proceedings, you bring against Heartland Psychotherapy LLC.
• Federal or state law requires it.

Special Provisions for PHI Related to Psychotherapy Notes or Substance Use Treatment:

Psychotherapy notes and records related to substance use treatment may be a part of your PHI. These portions of your health record require separate written consent that explicitly states the types of records that will be released or communication that can take place, the purpose of the release, the expiration date, and the person, agency, or entity the records are to be released to. 

Mandated Reporting

Under certain State Law, persons in designated professional occupations are mandated to report suspected child abuse or neglect of vulnerable adults. Persons who work with children and families are in a position to help protect children and vulnerable adults from harm. These persons may be required by law to report to authorities if they know or have a reason to believe that a person is being abused or neglected, and this may be done without your consent. Behavioral health personnel may be required to break confidentiality and report certain information to the appropriate authorities. 

Medical Power of Attorneys/Durable Power of Attorneys 

If you have a health care directive and have appointed a medical power of attorney or a durable power of attorney, this appointed person will have the ability to make medical decisions for you and access your PHI, but only in the case that you become incapacitated or incompetent. 

Adults who Have Guardians

If a guardian has been appointed to you through a court order, your guardian has the power to give necessary consent for you to receive medical or professional care and your guardian also has full access to your PHI. 

Minors

Minors are persons who are under the age of 18. Parents of certain minor children, who are able to consent for treatment on their own without their parent’s involvement, do not have access to their minor child’s health record and the release of records or PHI will require written consent from the minor child. The only exception to this is if the health care professional treating the minor believes that failure to inform the minor’s parent or guardian would seriously jeopardize the health of the minor patient. Minors who are able to consent for treatment on their own include:

• Minors who live apart or separately from their parents or legal guardians and is managing his or her own financial affairs.
• Minors who are married.
• Minors who are parents to a biological child. 
• When the services are to determine the presence of or to treat pregnancy and conditions associated therewith.
• When the services are related to venereal disease(s)/STDs/STIs.
• For Hepatitis B vaccinations.
• When the services are for the assessment or treatment of alcohol or drug abuse.
• Emergency treatment for medical, dental, or other health services if the risk to the minor’s life or health is of such a nature that treatment should be given without delay, and the requirement of consent would cause a delay in treatment. 

Additionally, parents may be deemed not to be personal representatives of their minor child, and therefore have limited or no access to their minor child’s PHI if the minor is subject to domestic violence, abuse, neglect, or endangerment and notifying the parent of the minor’s PHI may place the minor in further danger.