Notice of Privacy Practices

Connected Self Counseling, LLC

Tami Warenko, LCPC

Idaho (telehealth only)

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.

Connected Self Counseling, LLC (The Practice) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, for purposes other than uses for treatment, payment, health care operations, or otherwise excluded by law, or for which you provided me with an authorization.

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.
• You can file a complaint by contacting the Practice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• The Practice will not retaliate against you for filing a complaint.

USES, DISCLOSURES, AND COMMUNICATION OF PROTECTED INFORMATION

General Uses and Disclosures Not Requiring the Patient’s Consent.

  1. Treatment: Treatment refers to the provision, coordination, or management of healthcare (including mental healthcare) and related services. During treatment, the provider many consult with other providers, without identifying you by name, and also not disclosing any other identifying information about you, in order to ensure the best care possible for your concerns.

  2. Health Care Operations: The provider may use and disclose PHI for quality assurance, training, licensing, and other business activities.

  3. Payment: Payment refers to the activities undertaken by the provider to obtain or provide reimbursement for the provision of healthcare. For example, the provider will use your information to develop accounts receivable information, to bill you, and with your consent, to bill third parties. If you elect to have a third party pay for your treatment, the information provided to the third party may include information that identifies you as well as your diagnosis, type of service, and other information about your condition and treatment.

  4. Contacting the Patient: The provider may contact you to remind you of appointments, or to change or cancel appointments. The provider may leave messages on voicemail or with other parties, identifying the name and phone number of the provider. The provider will use best judgement in the details left on a voicemail. If you do not want the provider leaving messages, or if you wish to restrict the messages in any way, please notify the provider in writing.

  5. Required by Law: The provider will disclose protected health information when required by law or when necessary for healthcare oversight. This includes, but may not be limited to:

  • reporting child abuse or neglect;

  • when court ordered to release information;

  • when there is a legal duty to warn or take action regarding imminent danger to others;

  • when the patient is a danger to self or others or gravely disabled;

  • when a coroner is investigating the patient’s death.

  1. Public health and Safety
    Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
    • Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
    • Serious threat to health or safety: To prevent a serious and imminent threat.
    • Abuse or Neglect: To report abuse, neglect, or domestic violence.

  2. Family Members: Except for certain minors, protected health information cannot be provided to family members without the patient’s consent. In situations where family members are present during a discussion with the patient, and it can be reasonably inferred from the circumstances that the patient does not object, information may be disclosed in the course of that discussion. However, if the patient objects, protected health information will not be disclosed.

  3. Emergencies: In life-threatening emergencies, the provider will disclose information necessary to avoid serious harm or death.

  4. Patient Authorization or Release of Information

  5. The provider may not use or disclose protected information in any other way without a signed authorization or release of information. When you sign an authorization, or a release of information, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent the provider has already taken action in reliance thereon.

Alternative Means of Receiving Confidential Information:

You have the right to request that you receive communications of protected health information from the provider by alternative means or at alternative locations. For example, if you do not want the provider to mail statements or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests. You will also have to pay any additional costs that may be associated with such a request.

Protection of Confidential Information:

  • The Practice is required by law to maintain the privacy and security of PHI.

  • The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.

  • The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website, www.connectedselfcounseling.com.

  • The Practice will inform you if PHI is compromised in a breach.