HIPAA Notice of Privacy Practices

Sea Glass Counseling and Consultation, LLC

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

Our goal is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to: (1) maintain the privacy of medical information provided to us; (2) provide notice of our legal duties and privacy practices; and (3) abide by the terms of our Notice of Privacy Practices currently in effect.

I. Uses and Disclosures for Treatment and Health Care Operations

Sea Glass Counseling and Consultation, LLC may use or disclose your protected health information (PHI), for treatment and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

"PHI" refers to personal and identifiable health information about you in your health record.

"Treatment and Health Care Operations": Treatment is when we provide, coordinate, or manage your health care and other services related to your healthcare. An example of treatment would be when we consult with another health care provider, such as your physician or another licensed psychologist, counselor, or social worker.

“Health Care Operations” are activities that relate to the performance and operation of our agency. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, billing of services and payment activities, and case management and care coordination. Examples of payment activities include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain information, or to determine or fulfill its responsibilities for coverage, and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims including all health plans, Medicare, Medicaid, and other payers; (c) medical necessity and appropriateness of care reviews, utilization review activities.

"Disclosure" applies to activities outside of our agency such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Sea Glass Counseling and Consultation, LLC may use or disclose PHI for purposes outside of treatment and health care operations with your appropriate authorization. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. If we are asked for information for purposes outside of treatment and health care operations, we will obtain an authorization from you before releasing this information.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that we have relied on that authorization.

An Authorization is required for: (1) most uses and disclosures of psychotherapy notes; (2) uses and disclosures of Protected Health Information for marketing purposes; and (3) disclosures that constitute a sale of Protected Health Information; other uses and disclosures not described in the Notice of Privacy Practices will be made only with authorization from the individual.

III. Uses and Disclosures with Neither Consent nor Authorization

Sea Glass Counseling and Consultation, LLC may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If, in our professional capacity, we know or suspect that a child under 18 years of age or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, we are required by law to immediately report that knowledge or suspicion to the Ohio Public Children Services Agency, or a municipal or county peace officer.

Adult and Domestic Abuse: If we have reasonable cause to believe that an adult is being abused, neglected, or exploited, who resides in Ohio and is unable to provide for his or her own care and protection because of the infirmities of aging or physical or mental impairment, we are required by law to immediately report such belief to the County Department of Job and Family Services.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release this information without written authorization from you or your or legally-appointed representative, or a court order. The 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: If your counselor believes that you pose a clear and substantial risk of imminent serious harm to yourself or another person, we may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and we believe you have the intent and ability to carry out the threat, then we are required by law to take one or more of the following actions in a timely manner: 1) take steps to hospitalize you on an emergency basis, 2) establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional, 3) communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s).

Worker’s Compensation: If you file a worker’s compensation claim, we may be required to give your mental health information to relevant parties and officials.

Military Activity and National Security: Military and veterans activities when the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel for activates deemed necessary by appropriate military command authorities; for the purpose of a determination by the Department of Veterans Affairs of eligibility for benefits or to foreign military authority if you are a member of the foreign military services. We may also disclose your PHI to authorized federal officials for conducting national security intelligence activities, including for the provision of protective services to the President or others legally authorized.

IV. Patient's Rights and Counselor/Social Worker/Psychologist Duties

Patient's Rights:

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we aren’t required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and alternative locations. (For example, you may not want a family member to know that you are a client here). We may require written requests. Upon your request, we will send any communications to an alternate address.

Right to Inspect and Copy: You have the right to both inspect and obtain a copy of your protected health information (i.e., your case file). At your request, we will discuss with you the details of the request process after the request is received in writing. Your designated record set is a group of records we maintain that includes Medical records and billing records about you, or enrollment, claims adjudication, and case or medical management records systems, as applicable. You have the right of access in order to inspect and obtain a copy of your personal health information contained in your designated record set, except for (a) psychotherapy notes, (b) information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and (c) health information maintained by us to the extent to which the provision of access to you would be prohibited by law. We require written requests for your PHI. We must provide you with access to your personal health information in the form or format requested by you, if it is readily producible in such form or format, or, if not, in a readable hard copy form or such other form or format. We may provide you with a summary of the personal health information requested, in lieu of providing access to the personal health information or may provide an explanation of the personal health information to which access has been provided if it may be harmful to your treatment and care, if you agree in advance to such a summary or explanation and agree to the fees imposed for such summary or explanation. We will provide you with access as requested in a timely manner, including arranging with you a convenient time and place to inspect or obtain copies of your personal health information or mailing a copy to you at your request. We will discuss the scope, the format, and other aspects of your request for access as necessary to facilitate timely access. If you request a copy of your personal health information or agree to a summary or explanation of such information, we may charge a reasonable cost- based fee for copying, postage, if you request a mailing, and the costs of preparing an explanation or summary as agreed upon in advance. Section 13405(e) provides that when a counselor uses or maintains an electronic health records with respect to Protected Health Information, you have a right to obtain from the counselor a copy of such information in an electronic format and you may direct the counselor to transmit such copy directly to the individual's designee, provided that any such choice is clear, conspicuous, and specific. We reserve the right to deny you access to copies of certain personal health information as permitted or required by law.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.

Right to a Paper Copy: You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically. Unless, you decline a copy, you will receive a copy of this notice.

Right to Notice: You have the right to be notified following a breach of unsecured Protected Health Information.

The Final Rule modifies 164.522 as per HITECH Act Section 13405(a) indicating that individuals have a new right to restrict certain disclosures of Protected Health Information to a health plan where the individual pays out of pocket in full for the healthcare item or service.

Counselor Duties:

We are 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.

We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

If we revise our policies and procedures, we will provide you with notice via email or mail, if we have your current address. Any changes will be available in your client portal. You may request a copy of our current policy at any time.

V. Complaints

If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision they make about access to your records, you may file a complaint with your therapist and they will consider how best to resolve your complaint.  Contact your therapist, who acts as their own Privacy Officer, if you wish to file a complaint against them.  In the event that you aren’t satisfied with the response to your complaint, or don’t want to first file a complaint with them, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 200 Independence Avenue S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants/.

There will be no retaliation against you for filing a complaint.

VI. Effective Date

This notice will go into effect on January 1, 2021.

VII. Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.