Notice of 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.
PROTECTED HEALTH INFORMATION: In the course of treatment, information regarding your care may be
created and/or received. Information which can be used to identify you and which relates to your
past, present of future physical or mental condition, receipt of care or payment for care is
considered protected information and is protected by federal and state law.
Federal law imposes certain obligations and duties upon providers of services with respect to your
protected information. Specifically, I am required to:
• Provide you with notice of my legal duties and policies regarding the use and disclosure of your
• Maintain the confidentiality of your protected information in accordance with state and federal
• Honor your requested restrictions regarding the use and disclosure of your protected
information, unless under the law we are authorized to release your protected information without
• Allow you to inspect and copy your protected information;
• Act on your request to amend protected information, although I am not required to amend the
protected information, within sixty (60) days and notify you of any delay which would require me to extend the deadline by the permitted thirty (30) day extension;
• Accommodate reasonable requests to communicate protected information by alternative means or
• Notify you of any breach in your protected health information with sixty (60) days of discovery;
• Abide by the terms of this notice.
HOW YOUR PROTECTED INFORMATION MAY BE USED AND DISCLOSED
Generally, your protected information may be used and disclosed only with your express written
authorization. This written authorization includes to whom the information may be disclosed, what
information may be disclosed, and for what purpose. You may revoke this authorization at any time,
although any information released prior to the revocation may be used as stated on the consent.
There are some exceptions to this general rule. The following explains how Path to Peace
Counseling, PLC will use or disclose your protected information without your authorization:
• Treatment Purposes: Path to Peace Counseling, PLC may use or disclose your protected information
for treatment purposes to doctors, nurses, hospitals, for instance, in order to facilitate your
• Payment Purposes: Your protected information may be used or disclosed to your insurance company,
for instance, for payment purposes as it may be necessary to disclose this information so that I
may properly receive payment for treatment and services provided.
• Health Care Operations: Your protected information may be used or disclosed for health care
operations. For example, record review related to quality assurance and improvement activities or
third party system related to scheduling/billing operations.
• Compliance and Quality Assurance: I may release your protected information to another individual
or entity covered by the HIPPA privacy regulations that has a relationship with you for fraud and
abuse detection or compliance purposes, quality assessment and improvement activities, or review,
evaluation or training of professionals or students.
• Oversight Activities: Your protected information may be used or disclosed to an oversight agency
for activities authorized by law. Examples of oversight activities include audits, investigations,
and inspections. In most cases, the oversight activity will be for the purpose of overseeing
services and agency compliance with certain laws and regulations.
• Judicial and Administrative Proceedings: If you are involved in a lawsuit or other
administrative proceeding, I may release your protected information in response to a court or
administrative order. I may also release protected information pursuant to a subpoena or discovery
request, but only if efforts have been made by the requestor to provide you with notice of the
request and you have failed to object or the objection was resolved in favor of disclosure, or in
the alternative, the requestor has obtained a protective order protecting the requested
• Law Enforcement: I may release your protected information to law enforcement officials when
required or permitted by federal or state law to do so.
• Emergency Circumstances: Protected information may be disclosed to personnel who have a need for
information about a client, such as for the purpose of treating a medical or mental condition which
poses an immediate threat to the health and safety of any individual or the public and which
requires immediate intervention.
• Individuals Involved in Your Care: I may give out your protected information to a friend or
family member who is helping with your care or with payment for your care. However, prior to
sharing your protected information in this instance I will first attempt to obtain your verbal or
written consent. An example of when obtaining such consent would not be feasible would be if you
are in an accident and unavailable to give your consent and it is necessary for me to speak with your
emergency contact or other responsible party.
• Mandatory Reporting of Child Abuse/Dependent Adult Abuse: I am a mandatory reporter of child
abuse and dependent adult abuse. In the event that there is reason to suspect that child abuse or
dependent adult abuse has occurred, your protected information may be disclosed as required by law.
• As Authorized by Law: I will disclose your protected information for reasons not described above
when required by law to do so.
• More Stringent Laws: Some of your protected information may be subject to other laws and
regulations and are afforded greater protection than what is outlined in this Notice. For instance,
HIV/AIDS, substance abuse, and mental health information is often given more protection. In the
event your protected information is afforded greater protection under federal or state law, I will
comply with the applicable law.
Federal law grants you certain rights with respect to your protected information. Specifically, you
have the right to:
• Receive notice of Path to Peace Counseling, PLC’ policies and procedures used to protect your
• Request that certain uses and disclosures of your protected information be restricted, provided,
however, if I release the information without your consent or authorization, I have the right to
refuse your request;
• Access to your protected information be amended, although I am not required to grant your
• Obtain an accounting of certain disclosures of your protected information for the past six (6)
• Revoke any prior authorizations for use or disclosure of protected information, except to the
extent that action has already been taken; and
• Request that communications of your protected information are done by alternative means or at
IMPORTANT CONTACT INFORMATION
This notice has been provided to you as a summary of how Path to Peace Counseling, PLC will use
your protected information and what your rights with respect to your protected information are. If
you have any questions or would like more information regarding your protected information, please speak with me directly about this. You may file a complaint with the Department of Health and Human Services. There will be no retaliation for the filing of a complaint.