Spanish

THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; assessing your condition and determining the appropriate treatment; referring you to another professional; consulting with another professional with respect to your care; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health insurance coverage, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at all. Such uses or disclosures are: when a state or federal law mandates that certain health information be reported for a specific purpose, for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices, uses or disclosures for victims of suspected abuse, neglect or domestic violence, uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health courts or administrative agencies, disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime in our office; or to report a crime that happened somewhere else, disclosures relating to worker’s compensation programs, disclosures of a “limited data set” for research, public health, or health care operations, incidental disclosures that are an unavoidable by-product of permitted uses or disclosures or disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information. Unless you object, we will also share relevant information about your care with your family, friends, or other caregivers to the extent that the information directly relates to that person’s involvement in your care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we may leave you a reminder message on your answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written “authorization form” with content mandated by federal law. We may initiate the authorization process if the use or disclosure is our idea or you may initiate the process for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it.

Revocations must be in writing to the Compliance Officer at our office.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:

• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. In general, we do not have to agree to do this, but if we agree, we must honor the restrictions that you want. You do have a right to restrict us from disclosing any information to your health plan if you elect to pay for all goods and services out of pocket in full, the information is for the purpose of carrying out payment or operations (and is not for purposes of carrying out treatment) and you specifically request that we do not submit a claim or otherwise provide any such information regarding those goods or services to the health plan. To ask for a restriction, send a written request to the Compliance Officer at our office.
• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost involved. If you want to ask for confidential communications, send a written request to the Compliance Officer at our office.
• Ask to see or get photocopies of your health information. If we maintain the information electronically, you have a right to request an electronic copy of such information. By law, there are a few limited situations in which we can refuse to permit access or copying. However, for the most part, you will be able to review or have a copy of your health information within 15 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies or the cost of making an electronic copy in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access, photocopies or electronic copies if we send you a written notice of the extension. If you want to review, get photocopies or electronic copies of your health information, send a written request to the Compliance Officer at our office.
• Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the Compliance Officer at our office.
• Obtain a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will generally not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. If we maintain records electronically, disclosures for treatment, payment or health care operations will be included, but we are only required to provide such information for the three years prior to the request. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list or additional paper copies of this Notice of Privacy Practices, send a written request to our Compliance Officer.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practice (NPP) until we revise it. We reserve the right to change this notice at any time as allowed by law. If we change the NPP, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our NPP, we will post the new notice in our office, make copies available and post it on our Website.

FOR MORE INFORMATION

If you think that we have not properly respected the privacy of your health information, you are free to complain to our office or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you prefer to complain directly to us or want more information regarding our privacy practices, please contact the Compliance Officer by emailing [email protected] or writing:

Dr. Heather Jennett Director of Clinical Services
Little Leaves Behavioral Services
9545 Georgia Avenue Silver Spring, MD 20910