The NOTICE describes how your therapy and medical information may be used and disclosed and how you can get access to this information. Please review the document carefully.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations: I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations with your consent.

- "PHI" refers to information in your health record that could identify you.
- "Treatment, Payment and Health Care Operations"
Treatment: when a therapist provides, coordinates, or manages your health care and other services related to your health care.
Payment: when a therapist discloses PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations: activities that relate to performance and operation of our practice.
- "Use" applies only to activities within the practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- "Disclosure" applies to releasing, transferring, or providing access to information to other parties.

 

II. Uses and Disclosures Requiring Authorization: Your therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your written authorization is obtained. You may revoke an authorization at any time either in writing or electronically. You may not revoke an authorization to the extent that (1) that authorization has been relied on; or (2) the authorization was used to obtain insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization: Your therapist may use or disclose PHI without your consent or authorization in the following circumstances:

- Child Abuse: If your therapist knows, or has reasonable cause to believe or suspect that a child has been abused or neglected, or if your therapist observes any child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, your therapist must immediately report it to the Department of Family Services or law enforcement.
- Adult and Domestic Abuse: If your therapist has reasonable cause to believe that an elderly or disabled adult is being or has been abused, neglected, exploited, abandoned, or self-neglected, your therapist must immediately report it to Adult Protective Services or law enforcement.
- Health Oversight: If you file a complaint against your therapist with the State Board, your therapist may disclose to them confidential information that is relevant to that complaint.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for your diagnosis and treatment, such information is privileged under state law, and will not be released without written authorization from you, your legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the
evaluation is court ordered. You will be informed in advance if this is the case.
- Serious Threat to Health or Safety: Your therapist shall not disclose any information communicated for the purpose of diagnosis, evaluation or treatment of any mental or emotional condition or disorder, in the absence of an express waiver of the privilege except where an immediate threat of physical violence against a readily identifiable victim is disclosed to your therapist.
- Worker's Compensation: If you file a worker's compensation claim, that is a release of information for the duration of the benefit period, and upon request and notice to you, your therapist must release records pertaining to your injury to your Worker’s Compensation Division or employer. There may be additional disclosures of PHI that your therapist is required or permitted by law to make without your consent or authorization; however, the disclosures listed above are the most common.

IV. Patient's Rights and Therapists’ Duties

Patient's Rights:
- Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, your therapist is not required to agree to requests.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive PHI by alternative means and at alternative locations.
- Right to Inspect and Copy: You have the right to inspect or obtain a copy of PHI used to make decisions about you for as long as the PHI is maintained in the record. Your therapist may deny your access under certain circumstances, which will be discussed.
- Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request.
- Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI.
- Right to a Paper Copy: You have the right to obtain a paper copy of the notice from us upon request.
Therapist’s Duties:
- Your therapist is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
- Your therapist reserves the right to change the privacy policies and practices. Your therapist is required to abide by the terms currently in effect unless you are notified of changes.
- If your therapist revises policies and procedures, your therapist will provide an updated Notice to you at your next appointment or by mailing a copy to your last known address.

V. Questions and Complaints: If you have questions about this notice, disagree with a decision your therapist makes about your records, or have other concerns about privacy rights, contact Dr. Kilwein at (307) 223-2049. If you believe that your privacy rights have been violated and wish to file a complaint, send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have rights under the Privacy Rule. Your therapist will not retaliate against you for filing a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy: This notice will go into effect once signed. Your signature indicates that you have had the opportunity to review the NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION and agree to its terms.