Notice of Privacy Practices

As Required by the Privacy Regulations (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.  PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

This practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI).  In conducting business, we will create records regarding you and the treatment and services we provide to you.  This practice is required by law to maintain the confidentiality of health information that identifies you.  I also am required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI.  By federal and state law, Val Broste Counseling Services, LLC must follow the terms of the notice of privacy practices that we have in effect at the time.

I realize that these laws are complicated, but I must provide you with the following important information:

  • How we may use and disclose your IIHI
  • Your privacy rights in your IIHI
  • Our obligation concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice.  We reserve the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment to this notice will be effective for all of your records that my practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. My practice will post a copy of our current Notice in my office in a visable location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

 Val Broste Counseling Services, LLC
110 2nd Street South
Waite Park, MN, 56387
(320) 253-4080

 *Hereinafter referred to as “the provider

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS:

  1. Treatment.  This practice may use your IIHI to treat you.  For example, we may be required to disclose a treatment plan to your insurance carrier, or we may elect to consult with fellow therapists within Val Broste Counseling Services for a second opinion.  Many of the people who work for our practice- including, but not limited to, our therapists, your primary care physician and/or our billing center staff- may use or disclose your IIHI in order to treat you or assist others in your treatment.  Additionally, we may disclose your IIHI to others who may assist in your care, such as parents of minor children, as well as any legally appointed guardian.
  2. Payment.  This practice may use and disclose your IIHI in order to bill and collect payment for the services and/or items that you receive from us.  For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.  We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members.  Also, we may use your IIHI to bill you directly for services and/or items.
  3. Health Care Operations.  This practice may use and disclose your IIHI to operate our business.  As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care received from us, or to conduct cost-management and business planning activities for the practice.
  4. Third-Party Billing Center.  This practice uses an outside, third-party billing center to process claims and deal with reimbursement issues.  This includes, but is not limited to, filing your claims to your insurance company, sending you statements on your account, and following up with your for information needed to process said claims or receive payment on outstanding invoices.  You may request contact information for our billing center at any time asking the provider.
  5. Appointment Reminders.  This practice may use and disclose your IIHI to contact you and remind you of an appointment.
  6. Release of Information to Family/Friends.  This practice may release your IIHI to a friend  or family member that is involved in your care, or who assists in taking care of you.  For example,  a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold.  In this example, the babysitter may have access to this child’s medical information.
  7. Disclosures Required By Law.  This practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES

  1. Public Health Risks.  This practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:
    • Reporting child abuse or neglect
    • Preventing prenatal exposure to non-prescribed mood-altering chemicals
    • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
  2. Health Oversight Activities.  This practice may disclose your IIHI to a health oversight agency for activities authorized by law.  Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
  3. Lawsuits and Similar Proceedings. This practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.  We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
  4. Deceased Patients.  This practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death.  If necessary, we also may release information in order for funeral directors to perform their jobs.
  5. Serious Threats to Health or Safety.  This practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public; or in the event the therapist has reason to believe a pregnant client is using certain illegal drugs for non-medical purposes.  Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  6. National Security.  This practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law.  We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
  7. Workers compensation.  This practice may release your IIHI for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR IIHI

  1. Confidential Communications.  You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location.  For instance, you may ask that we contact you at home, rather than work.  In order to request a type of confidential communication, you must make a written request to the provider specifying the requested method of contact, or the location where you wish to be contacted.  This practice will accommodate reasonable requests.  You do not need to give a reason for your request.
  2. Requesting Restrictions.  You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations.  Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment of your care, such as family members and friends.  We are not required to agree to your request; however if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you.  In order to request a restriction in our use and disclosure of you IIHI, you must make your request in writing to the provider.  Your request must describe in clear and concise fashion:
    1. The information you wish restricted
    2. Whether you are requesting to limit our practice’s use, disclosure or both; and
    3. To whom you want the limits to apply
  3. Inspection and Copies.  You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes.  You must submit your request in writing to the provider in order to inspect and/or obtain a copy of your IIHI.  This practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.  This practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.  Another licensed health care professional chosen by us will conduct reviews.
  4. Amendment.   You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for us as long as the information is kept by or for this practice.  To request an amendment, your request must be made in writing and submitted to the provider.  You must provide us with a reason that supports your request for amendment.  This practice will deny your request if you fail to submit your request (and the reason for your request) in writing.  Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for this practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by this practice, unless the individual or entity that created the information is not available to amend the information.
  5. Accounting of Disclosures.  All of our patients have the right to request an “accounting of disclosures.”  An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations purposes.  Use of your IIHI as part of the routine patient care in this practice is not required to be documented.  For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim.  In order to obtain an accounting of disclosures, you must submit your request in writing to the provider. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003.  The first list you request within a 12-month period is free of charge, but this practice may charge you for additional requests, and you may withdraw your request before you incur any costs.
  6. Right to a Paper Copy of This Notice.  You are entitled to receive a paper copy of our notice of privacy practices.  You may ask us to give you a copy of this notice at any time.  To obtain a paper copy of this notice, contact the provider.
  7. Right to File a Complaint.  If you believe your privacy rights have been violated, you may file a complaint with this practice or with the Secretary of the Department of Health and Human Services.  To file a complaint with this practice, contact the provider.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.
  8. Right to Provide an Authorization for Other Uses and Disclosures.  This practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.  Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing.  After you revoke your authorization, we will no longer use or disclose your IIHI for reasons described in the authorization.  Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact:

Val Broste Counseling Services, LLC
110 2nd Street South
Waite Park, MN, 56387
(320) 253-4080