Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
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. This Notice of Privacy Practices applies to the organizations Forward Wellness Family Therapy, Inc. and Forward Wellness Inc.
I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND: How to get access to this information, please read it carefully. (Please note that this particular provision must be set forth in your notice of privacy practices exactly as it is set forth here.)
II. FORWARD WELLNESS FAMILY THERAPY, INC. AND FORWARD WELLNESS, INC. HAS A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH lNFORMATION (PHI): Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is legally required to protect the privacy of your PHI, which includes information that can be used to identify you that I've created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. must provide you with this Notice about its privacy practices, and such Notice must explain how, when, and why Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will "use" and "disclose" your PHI. A "use" of PHI occurs is when Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. shares, examines, utilizes, applies, or analyzes such information within its practice; PHI is "disclosed" when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of its practice. With some exceptions, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is legally required to follow the privacy practices described in this Notice. However, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. reserves the right to change the terms of this Notice and its privacy policies at any time. Any changes will apply to PHI on file with Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. already. Before Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. makes any important changes to its policies, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will promptly change this Notice. You can also request a copy of this Notice from Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.
III. HOW FORWARD WELLNESS FAMILY THERAPY, INC. AND FORWARD WELLNESS, INC.: MAY USE AND DISCLOSE YOUR PHI: Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will use and disclose your PHI for many different reasons. For some of these uses or disclosures, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will need your prior authorization; for others, however, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. does not. Listed below are the different categories of Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ uses and disclosures along with some examples of each category.
A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent: Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can use and disclose your PHI without your consent for the following reasons: For treatment. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if you're being treated by a psychiatrist, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can disclose your PHI to your psychiatrist in order to coordinate your care. To obtain payment for treatment. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can use and disclose your PHI to bill and collect payment for the treatment and services provided by Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. to you. For example, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.might send your PHI to your insurance company or health plan to get paid for the health care services that Forward Wellness has provided to you. Forward Wellness may also provide your PHI to its business associates, such as billing companies, claims processing companies, and others that process Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ health care claims. For health care operations. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can disclose your PHI to operate its practice. For example, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may also provide your PHI to our accountants, attorneys, consultants, and others to make sure we are com-plying with applicable laws. Other disclosures. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may also disclose your PHI to others with-out your consent in certain situations. For example, your consent isn't required if you need emergency treatment, as long as Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. tries to get your consent after treatment is rendered, or if Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. tries to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) and Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. thinks that you would consent to such treatment if you were able to do so.
B. Certain Uses and Disclosures Do Not Require Your Consent: Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can use and disclose your PHI without your consent or authorization for the following reasons: When disclosure is required by federal, state or Iocal law; judicial or administrative proceedings; or, law enforcement. For example, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may make a disclosure to applicable officials when a law requires Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. to report information to government agencies and law enforcement personnel about victims of abuse or neglect; or when ordered in a judicial or administrative proceeding. For public health activities. For example, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may have to report information about you to the county coroner. For health oversight activities. For example, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may have to provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization. For research purposes. In certain circumstances, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may provide PHI in order to conduct medical research.To avoid harm. In order to avoid a serious threat to the PHI to law enforcement personnel or persons able to prevent or lessen such harm. For specific government functions. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.may disclose PHI of military personnel and veterans in certain situations. And Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations. For workers' compensation purposes. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.may provide PHI in order to comply with workers' compensation laws. Appointment reminders and health related benefits or services. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. offers.
C. Certain Uses and Disclosures Require You to Have the Opportunity to Object: Disclosures to family, friends, or others. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization: In any other situation not described in sections III A, B, and C above, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. hasn't taken any action in reliance on such authorization) of your PHI by Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI: You have the following rights with respect to your PHI:
A. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. limit how it uses and discloses your PHI. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.will consider your request, but is not legally required to accept it. If Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. accepts your request, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is legally required or allowed to make.
B. The Right to Choose How Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. Sends PHI to You: You have the right to ask that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. sends information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail) Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. must agree to your request so long as Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. can easily provide the PHI to you in the format you requested.
C. The Right to See and Get Copies of Your PHI: In most cases, you have the right to look at or get copies of your PHI that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has, but you must make the request in writing. If Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. doesn't have your PHI but Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. knows who does, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will tell you how to get it. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will respond to you within 30 days of receiving your written request. In certain situations, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may deny your request. If Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. does, they will tell you, in writing, the reasons for the denial and explain your right to have the denial reviewed. If you request copies of your PHI, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will charge you not more than $.25 for each page. Instead of providing the PHI you requested, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
D. The Right to Get a List of the Disclosures Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. Has Made: You have the right to get a list of instances in which Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, or to your family. The list also won't include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will provide the list to you at no charge, but if you make more than one request in the same year, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will charge you a reasonable cost based fee for each additional request.
E. The Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. corrects the existing information or add the missing information. You must provide the request and your reason for the request in writing. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will respond within 60 days of receiving your request to correct or update your PHI. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. , (iii) not allowed to be disclosed, or (iv) not part of Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ records. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don't file one, you have the right to request that your request and Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ denial be attached to all future disclosures of your PHI. If Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. approves your request, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will make the change to your PHI, tell you that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has done it, and tell others that need to know about the change to your PHI.
F. The Right to Get This Notice by E-Mail: You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of it.
V. HOW TO COMPLAIN ABOUT FORWARD WELLNESS FAMILY THERAPY, INC. AND FORWARD WELLNESS, INC.S’ PRIVACY PRACTICES:
If you think that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. may have violated your privacy rights, or you disagree with a decision Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may send a written complaint to the HIPAA Privacy Officer at Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc., the Board of Behavioral Sciences (Link Below), or the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will take no retaliatory action against you if you file a complaint about Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ privacy practices.
Complaint Submission Instructions for Nationwide Regulatory Boards:
Licensed Professional Counselor (LPC,), Licensed Professional Clinical Counselor (LPCC), and Licensed Clinical Professional Counselor (LPCP):
California Board of Behavioral Sciences 1625 North Market Blvd., Suite S-200, Sacramento, CA 95834 (916) 557-1208 breeze@dca.ca.gov To File a Complaint: https://www.bbs.ca.gov/consumers/consumer_complaints.html
Licensed Social Worker (LCSW) and Licensed Independent Social Worker (LISW):
Board of Behavioral Sciences Attn: Public Mailing List 1625 N Market Blvd., #S200 Sacramento CA 95834 (916) 574-7830 To File a Complaint: https://www.bbs.ca.gov/consumers/consumer_complaints.html
Licensed Marriage and Family Therapist (LMFT):
Board of Behavioral Sciences Attn: Public Mailing List 1625 N Market Blvd., #S200 Sacramento CA 95834 (916) 574-7830 To File a Complaint: https://www.bbs.ca.gov/consumers/consumer_complaints.html
Psychologist (PhD, PsyD EdD):
California Board of Psychology 1625 North Market Blvd., Suite N-215 Sacramento, CA 95834 Email: See Below Web page: www.psychology.ca.gov Telephone: (916) 574-7720 Toll Free: (866) 503-3221 Fax: (916) 574-8672 To File a Complaint: https://www.psychology.ca.gov/consumers/index.shtml#complaints
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT FORWARD WELLNESS FAMILY THERAPY, INC. AND FORWARD WELLNESS, INC.S’ PRIVACY PRACTICES:
If you have any questions about this notice or any com-plaints about Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ privacy practices, or would like to know how to file a complaint with the Board of Behavioral Sciences, or the Secretary of the Department of Health and Human Services, please contact Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. at: Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. 1041 East Yorba Blvd Suite 202 Placentia, CA 92870, 800-701-0937, contact@forwardwellness.org.
VII. EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on April 14, 2003.
YOUR RIGHTS:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations.We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with Forward Wellness Family Therapy, Inc. and Foward Wellness, Inc., the Board of Behavioral Sciences, or 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/. We will not retaliate against you for filing a complaint.
YOUR CHOICES:
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. Include your information in a hospital directory. Contact you for fundraising efforts. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes, Sale of your information, Most sharing of psychotherapy note. In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES:
How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence, Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Board of Behavioral Sciences and the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: For workers’ compensation claims, For law enforcement purposes or with a law enforcement official, With health oversight agencies for activities authorized by law, For special government functions such as military, national security, and presidential protective services. Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena.
OUR RESPONSIBILITIES:
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
CHANGES TO THE TERMS OF THIS NOTICE: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective Date: October 11, 2013.
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: This notice is effective as of April 15, 2003.
USES AND DISCLOSURE OF HEALTH INFORMATION:
Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”. PHI typically includes your name, address, date of birth, billing arrangements, care, and other information that relates to your health, health care provided to you, or payment for health care provided to you. PHI DOES NOT include information that is de-identified or cannot be linked to you. This notice of Health Information Privacy Practices (the “Notice”) describes Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.s’ duties with respect to the privacy of PHI, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. use of and disclosure of PHI, client rights and contact information for comments, questions, and complaints.
PRIVACY PROCEDURES AND LEGAL OBLIGATIONS:
Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. obtains most of its PHI directly from you, through care applications, assessments and direct questions. We may collect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiries. We may also obtain PHI from community health care agencies, other governmental agencies or health care providers as we set up your service arrangements. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is required by law to provide you with this notice and to abide by the terms of the Notice currently in effect. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. reserves the right to amend this Notice at any time to reflect changes in our privacy practices. Any such changes will be applicable to and effective for all PHI that we maintain including PHI we created or received prior to the effective date of the revised notice. Any revised notice will be mailed to you or provided upon request. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is required by law to maintain the privacy of PHI. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below. In order to comply with these state and federal laws, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has adopted policies and procedures that require its employees to obtain, maintain, use and disclose PHI in a manner that protects client privacy.
USES AND DISCLOSURES WITH YOUR AUTHORIZATION:
Except as outlined below, Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will not use or disclose your PHI without your written authorization. The authorization form is available from Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. (at the address and phone number below). You have the right to revoke your authorization at any time, except to the extent that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has taken action in reliance on the authorization.The law permits Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. to use and disclose your PHI for the following reasons without your authorization: For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication or otherwise provide health care services to you.To Obtain Payment: We may use or disclose your PHI to insurance companies , government agencies or health plans to assist us in getting paid for our services . For example, we may release information such as dates of treatment to an insurance company in order to obtain payment. For Our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. workforce or to companies who help us perform our health services (referred to as "Business Associates") we require these business associates to appropriately protect the privacy of your information. As Permitted or Required By The Law: In some cases we are required by law to disclose PHI. Such as disclosers may be required by statute, regulation court order, government agency, we reasonably believe an individual to be a victim of abuse, neglect or domestic violence: for judicial and administrative proceedings and enforcement purposes. For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes. For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, auditing and for administration of government benefits.To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public. Disclosures of Health Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health related products or services offered at Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.. You have the right not to accept such information. Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a by-product of a permitted use or disclosure. Such incidental used and disclosures are permitted as long as Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. use reasonable safeguards and use or disclose only the minimum amount of PHI necessary. To Personal Representatives: We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law. We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative. To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care. These disclosures may occur when you are not present, as long as you agree and do not express an objection. These disclosures may also occur if you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest. We may also disclose limited PHI to public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you. You have the right to limit or stop these disclosures.
YOUR RIGHTS CONCERNING PRIVACY: Access to Certain Records:
You have the right to inspect and copy your PHI in a designated record set except where State law may prohibit client access. A designated record set contains medical and billing and case management information. If we do not have your PHI record set but know who does, we will inform you how to get it. If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them. If Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. produces copies for you, we may charge you up to $1.00 per page up to a maximum fee of $50.00. Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated by Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc.. Amendments to Certain Records: You have the right to request certain amendments to your PHI if, for example, you believe a mistake has been made or a vital piece of information is missing. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. is not required to make the requested amendments and will inform you in writing of our response to your request. Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI that were made by Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. for a period of six (6) years prior to the date of your written request. This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order. Restrictions: You have the right to request that we agree to restrictions on certain uses and disclosures of your PHI, but we are not required to agree to your request. You cannot place limits on uses and disclosures that we are legally required or allowed to make. Revoke Authorizations: You have the right to revoke any authorizations you have provided, except to the extent that Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. has already relied upon the prior authorization. Delivery by Alternate Means or Alternate Address: You have the right to request that we send your PHI by alternate means or to an alternate address.
Complaints & How to contact us: If you believe your privacy rights have been violated, you have the right to file a complaint by contacting Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. at the address and/or phone number indicated below. You also have the right to file a complaint with the Board of Behavioral Sciences or the Secretary of the United States Department of Health and Human services in Washington, D.C. Forward Wellness Family Therapy, Inc. and Forward Wellness, Inc. will not retaliate against you for filing a complaint. If you believe your privacy rights have been violated, you may make a complaint by contacting the HIPAA Privacy Officer at (800) 701-0937, the Board of Behavioral Sciences, or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint. The U.S.Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, Toll Free: 1-877-696-6775. Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001. Clients are to be given a copy along with a copy to be filed in the client chart. Forward Wellness Family Therapy Therapy, Inc. and Forward Wellness, Inc.