Joan Breault Counseling Services, LLC
NOTICE OF PRIVACY PRACTICES
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.
Joan Breault Counseling Services, LLC is committed to protecting the privacy of your health information for services you receive at Joan Breault Counseling Services, LLC. Your privacy rights are governed under provisions of both federal and state law. Regulations include, but are not limited to:
- New Hampshire state law regarding treatment records, confidentiality of records, confidentiality limitations, and reporting requirements.
- Any other federal laws such as Code of Federal Regulations, Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records.
- Health Insurance and Portability/Accountability Act of 1996 (HIPAA).
In addition, Joan Breault Counseling Services, LLC abides by ethical codes of conduct of the American Mental Health Counselor Association.
- I am required by law to maintain the privacy of your health information.
- I will let you know promptly if a breach of your health information occurs that may have compromised the privacy or security of your information.
- I must follow the duties and privacy practices described in this notice unless you tell me otherwise in writing. If you do so, you may change your mind at any time (you must provide notification to me in writing).
- I am required to abide by the terms of this notice until I officially adopt a new notice. I will provide a copy of the new notice.
- I am required to give you a copy of this notice.
Your Rights as a Patient:
- You have the right to get a copy of your paper or electronic medical record unless state law prohibits it. You may ask to see or receive an electronic or paper copy of your medical record and other information I have about you. Upon request, I will provide you a copy or a summary of your health information typically within 30 days of your request. You will be charged a reasonable, cost based fee.
- You have the right to ask me to correct your medical record. If you believe your medical record is incorrect or incomplete you may ask me to correct it. I have the right to decline your request, but I must do so in writing within 60 days.
- You have the right to ask me to contact you in a specific way. For example, you may want to be contacted at a specific phone number or to send your mail to an alternate address.
- You have the right to ask me to limit what I share with others. For example, you can ask me not to share certain health information that I use for treatment, payment, or business operations. I am not required to grant this request; I may decline your request if I believe it would affect your care.
- You have a right to ask for a list of the times I have shared your health information, who I have shared it with, and why. This accounting of disclosures of information can be for up to 6 years prior to the date you ask. The accounting will include all disclosures except for those we have made about your treatment, payment, or healthcare operations, and certain other disclosures, such as those you requested that I make. You are able to receive one such accounting per year; after that, I will charge a reasonable, cost-based fee if you ask for another accounting.
- You have the right to request not to share information with your insurer if you pay for services out of pocket. If you pay for services in full yourself, you can ask that I not share that information with your health insurer.
- You have the right to ask for a copy of this notice at any time. I will promptly provide it.
- You have the right to choose a personal representative. If you have given someone medical power of attorney or if you have a legal guardian, that person may exercise your rights and make choices about your health information. I will try to make sure this person has the proper authority prior to disclosing your information.
- You have the right to agree or object to my sharing of your health information under certain conditions. For example, you can tell me if you would like me to share information with your family, friends, or others involved in your care. You may also choose to tell me if you would like your health information shared in the event of a disaster so, for example, family or friends could locate you. In the event of an emergency and you are unable to tell me your preferences for these matters, I will use my professional judgment and share information if I believe it is in your best interest.
- You have the right to complain if you believe your privacy rights have been violated. I cannot retaliate should you file a complaint.
How We Use Your Health Information:
What follows are exceptions to your confidentiality; the health information that may be disclosed without your consent. Information that is disclosed in these situations will be kept to the minimum to meet the requirement or to the extent required by law.
I will use your health information in the following way:
- For Your Treatment. I may use your health information and share it with other professionals who are treating you. For example, a clinician treating you may need to speak with a psychiatrist or another clinician seeking input to increase the quality of your care.
- For Payment. I may use and disclose your health information in order to receive payment for services you obtain from me. For example, I may give limited information to your insurance company or other payer for billing and payment purposes.
- For My Healthcare Operations. I may use and disclose your healthcare information for administrative purposes. For example, I may use your healthcare information for quality assessment and improvement functions, or accreditation or licensing activities.
Other Uses and Disclosures of your Health information:
I can also share health information about you for certain situations such as:
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- For worker’s compensation claims (as the law allows)
- Reporting adverse reactions to medications
- Complying with the law
- For health research
- Preventing disease
- Helping with product recalls
- For law enforcement purposes or with a law enforcement official as indicated or allowed by law
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
- Responding to lawsuits and legal actions
- In response to a court or administrative order, or in response to a subpoena
- To family members involved in your care unless you have objected
- With a personal health representative whom you have designated
- For research purposes if certain conditions are met
- Responding to organ and tissue donation requests
- Working with a coroner, medical examiner, or funeral director
- For certain specialized government functions (e.g prisons, military)
- To Business Associates (Certain services are performed through contract with outside persons or organizations. My Business Associates abide by written contracts that obligates them to safeguard your information in the same manner I do
Special Protections for your Psychotherapy Notes:
- Your psychotherapy notes are afforded additional protections under the law. Psychotherapy notes are “notes recorded (in any medium) by mental health professionals documenting or analyzing the contents of a conversation during a private counseling session or group, joint, or family counseling session”. Psychotherapy notes are kept separate from your medical record. Psychotherapy notes do not include treatment information including medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, your treatment plan, symptoms, prognosis, and progress. These may be included in your medical record and may be used to carry out treatment, payment, or my healthcare operations as discussed above.
- Your psychotherapy notes will not be released without your express written permission, except under the following circumstances: by the healthcare provider who created the notes for oversight purposes, when needed by the coroner or medical examiner, or when needed to avert a serious or imminent threat to the health or safety of yourself or others. In the event of legal action against me, I may use your psychotherapy notes to defend myself in legal proceedings.
How I Will Not Use Your Protected Health Information:
- I will not use your protected health information for marketing purposes without your written permission.
- I will not share psychotherapy notes in most cases without express written authorization from you.
- I will not sell your health information.
Minors in treatment:
- Minors’ privacy is regulated by state law
If You Believe Your Privacy Rights Have Been Violated:
If you believe your privacy rights have been violated, you have the following rights:
- You may complain to me if you feel I have violated your rights by contacting me at 603-874-4440, firstname.lastname@example.org.
- You may also 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, DC 20201, or by calling 1-877-696-6775 or vesting www.hhs.gov/ocr/privacy/hipaa/complaints/.
You may revoke this authorization at any time in writing. For any further information needed, please contact me at 603-874-4440.
Changes to the Terms of this Notice: I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office, and on my website.
Client/Guardian signature and Date
Joan Breault, EdD., LCMHC
2 Washington St., Suite 301 / Dover, NH 03820 / Drjoanbreault@gmail.com / 603.874.4440