INFINITE POSSIBILITIES COUNSELING SERVICES, INC.
4535 Normal Boulevard, Lincoln, NE 685006
e-mail: medicaltherapist@yahoo.com
Notice of Information 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.
Infinite Possibilities Counseling Services, Inc. is required by federal law to maintain the privacy of Protected Health Information and to provide notice of its legal duties and privacy practices with respect to Protected Health Information. This notice fulfills the “Notice” requirements of the Health Information Portability and Accountability Act of 1996 (HIPAA) Final Privacy Rule. If you have further questions contact Lindy L. Bixler, M.S. at the above-listed address and phone number, or e-mail at: medicalfamilytherapsit@yahoo.com
Please note: Infinite Possibilities Counseling Services, Inc. does not electronically transfer PHI information.
This Notice is published and becomes effective: April 14, 2003
This Notice of Information Privacy Practices explains how Infinite Possibilities Counseling Services, Inc. will use or disclose your Protected Health Information for the purposes of diagnosis, treatment, obtaining payment for your health care bills, or to conduct mental healthcare operations. Protected Health Information includes records, notes, and reports,, claims, etc. that are individually identifiable.
Infinite Possibilities Counseling Services, Inc. engages in the following practices involving the use and disclosure of Individually Identifiable Health Information to carry out treatment, payment, and health care operations:
For Treatment: We may use the medical, and mental and health information you provide to allow us to recommend appropriate mental health and/or medical treatment or services. ONLY with your written consent and knowledge, may we disclose medical or mental health information about you to doctors, nurses, technicians, medical students, or other health care personnel who are involved in your treatment.
Emergencies: We may use or disclose your Protected Health Information in an emergency treatment situation. If this happens, your physician/psychiatrist or other medical personnel will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If the medical personnel has attempted to obtain your consent but is unsuccessful, he or she may still use or disclose your Protected Health Information to treat you.
For Payment: We may use and disclose your mental health information so that the treatment and services you receive at a this facility may be billed; also, so that payment may be collected from you, an insurance company, or a third party. We may also use your information to obtain prior approval for a treatment you may receive, or, to determine whether a third party will cover the treatment.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object for Purposes Other Than Treatment, Payment, or Health Care Operations
Infinite Possibilities Counseling Services, Inc. is permitted to make the following uses and disclosures of Individually Identifiable Health Information should circumstances warrant such uses and disclosures:
vRequired By Law: We may use or disclose your Protected Health Information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
vPublic Health: We may disclose your Protected Health Information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purposes of preventing or eliminating a suspected threat of life or harm to self or to others.
vAbuse or Neglect: We may disclose your Protected Health Information to a public health authority that is authorized by law to receive reports of abuse or neglect of vulnerable adults and children.
vLegal Proceedings: We may disclose Protected Health Information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process.
vLaw Enforcement: We may also disclose Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (1) legal processes and purposes otherwise required by law, (2) limited information requests for identification and location purposes, (3) treating victims of a crime, and (4) suspicion that death has occurred as a result of criminal conduct.
vCriminal Activity: Consistent with applicable federal and state laws, we may disclose your Protected Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.
vWorkers’ Compensation: We may disclose your Protected Health Information as authorized to comply with workers compensation laws and other similar legally established programs.
vRequired Uses and Disclosures: Under the law, we must make disclosures when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements of 45 CFR, Title II, Section 164, et. seq.
You have the following rights regarding medical information we maintain about you:
vRight to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records but does not include psychotherapy notes.
To inspect and copy your medical information, you must submit your request in writing to Infinite Possibilities Counseling Services, Inc. at the address on the top of this Notice. If you request a copy of information, we may charge a fee for the cost of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request the denial be reviewed. For more information call (402) 429-8828.
vRight to Amend. If you feel that medical information about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by or for Infinite Possibilities Counseling Services, Inc. To request an
Amendment, your request must be made in writing and submitted to Infinite Possibilities Counseling Services, Inc. at the address on the top right of this Notice. In addition you must provide a reason which supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
§ Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
§ Is not part of the medical information kept by or for Infinite Possibilities Counseling Services, Inc.
§ Is not part of the information which you would be permitted to inspect and copy; or,
§ Is accurate and complete.
vRight to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this list, you must submit your request in writing to Infinite Possibilities Counseling Services, Inc. at the address on the top of this Notice. Your request must state a time period for the disclosures, which may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list to be provided to you: for example, on paper, or by e-mail.
vRight to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
vWe are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Infinite Possibilities Counseling Services, Inc. at the address on the top of this Notice. In your request you must tell us: (1) what information you want to limit, (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply; for example, disclosures to your spouse.
vRight to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Infinite Possibilities Counseling Services, Inc. at the address on the top right of this form. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
vRight to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at the website, http://www.medicaltherapist.net or via e-mail: medicaltherapist@yahoo.com To obtain a paper copy of this notice, call (402) 429-8828 and leave a message during regular working hours.
If you believe your privacy rights have been violated, you may file a complaint with Infinite Possibilities Counseling Services, Inc. at the addres listed on the top of this form. To file a complaint with HHS, contact: Secretary, Health and Human Services, Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201, 1-866-OCR-PRIV (627-7748), 1-866-778-4989-TTY. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care we provided to you.
Changes to the Notice of Information Practices
Infinite Possibilities Counseling Services, Inc. reserves the right to amend this Notice at any time in the future. Until such amendment is made, Infinite Possibilities Counseling Services, Inc. is required by law to abide by the terms of this Notice.
Acknowledgment of receipt of this notice:
________________________________ Date:_______________
Signature of Recipient p Individual
p Personal Representative