Both State and Federal law require healthcare agencies to maintain the privacy of your health information. Health care agencies are required to give you this Notice about privacy practices, legal obligations, and your rights concerning your health information (“Protected health Information” or “PHI”). If you ever have any questions about privacy practices, please contact the office by email at email@example.com. Additional copies of this Notice can be obtained through the website: www.ballardpsych.com
Uses and Disclosures of Protected Health Information (PHI)
Confidentiality is an essential aspect of mental health services. Ballard Psychiatric Associates, PLLC will not disclose any information about your care, including the fact that you are or have been a patient, without your written consent. If you provide written consent, you maintain the right to revoke that permission at any time. The possible legal exceptions to this policy are listed below.
Permissible Uses and Disclosures without Your Written Authorization
1. Where there is reason to suspect the occurrence of abuse or neglect of a child, a dependent adult, or a developmentally disable person.
2. Where there is a clear threat to do serious bodily harm to yourself or others.
3. In a response to a subpoena issued by the Secretary of Heath that is associated with a regulatory complaint.
4. Disclosures for public health activities.
5. Disclosures related to communicable diseases.
6. Health oversight activities including disclosures to state or federal agencies authorized to access PHI
7. If you are involved in some legal action, a court order might require your records.
8. Disclosures for research when approved by an institutional review board.
9. Disclosures to military or national security agencies, coroners, medical examiner, and correctional institutions.
10. In the event of an emergency, emergency personnel or service providers may be given necessary information.
11. In the event of the client’s death or disability, information may be released if the client’s personal or the beneficiary of an insurance policy on the client’s life signs a release authorizing disclosure.
12. In the event you reveal the contemplation or commission of a crime or harmful act.
13. For auditing purposes or state licensing review or as otherwise authorized by law.
14. Your PHI will not be used for marketing or fundraising communications without your written consent.
15. Uses and disclosures other than those described above will only be made with your written authorization. For example, you will need to sign an authorization form before I could send PHI to your attorney. You may revoke any such authorization at any time.
Your Individual Rights
• Right to inspect and copy: You may request access to your medical and billing records maintained by me in order to inspect and request copies of these records. All requests must be made in writing. You have the right to appeal any denials. You may be charged charge a fee for the costs of copying and sending you any requested records.
• Right to alternative communication: You may request any reasonable written request for you to receive alternative means of communication or at alternative locations.
• Right to request restrictions: You have the right to request restrictions on certain uses and disclosure of your healthcare information used for treatment, payment, or operations.
• Right to request amendment: You have the right to request that your PHI be amended. Your request must be in writing and your request may be denied under certain circumstances.
• Right to obtain notice: You have the right to obtain a copy of this Notice by contacting the office directly or through accessing the website at www.ballardpsych.com
Question and complaints: If you believe your privacy rights have been violated, you may file a complaint in writing with Ballard Psychiatric Associates, PLLC, and/or with the Secretary of the Department of Health. You will not be retaliated against for filing such a complaint. You may contact the Dept. of Health at 360-236-4700, or by writing to Washington State Department of Health, Health Systems Quality Assurance, PO Box 47850, Olympia, WA 98504-7850. You can access information on acts of unprofessional conduct online at http://www.legal.wa.gov/wsladm/rcw.htm. You may also file written complaints with the Director, Office for Civil Rights of the US Department of Health and Human Services.
Ballard Psychiatric Associates, PLLC is required by law to abide by the terms of this document, though it is legally allowed to change the terms, and to make the provisions of any modified version effective for all healthcare information provided. You may request that a modified version be given to you or you may access a current electronic version through the website: www.ballardpsych.com.