This notice describes how medical and health information about you may be used and disclosed by Shannon Francom, Ph.D., LMFT (also referred to as “this entity”), and how you can get access to this information. Please review it carefully.
Your Rights You have the right to:
Request a summary of your medical record - You may request from this entity to see or receive a summary of your medical record and other health information. If your request is granted, you will be provided a copy or a summary of your health information, usually within 30 days of your request. You may be charged a reasonable, cost-based fee.
Correct your medical record - You may request to correct health information about you that you think is incorrect or incomplete. This entity may say “no” to your request, but will provide the reason in writing within 60 days.
Request confidential communication - You may ask this entity to contact you in a specific way (for example, home or office phone) or to send mail to a different address. This entity will say “yes” to all reasonable requests.
Ask the practice to limit the information shared - You may request this entity not to use or share certain health information for treatment, payment, or business operations. This entity is not required to agree to your request, and may say “no” if it would affect your care. Because you pay for services in full, out-of-pocket, this entity will not share your information for the purpose of payment or this entity’s operations with your health insurer, unless you give written permission in instances when you are seeking reimbursement from your health insurer.
Receive a list of those with whom this entity has shared your information - You may ask for a list (accounting) of the times this entity has shared your health information for six years prior to the date you ask, with whom this entity shared it, and why. This entity will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Receive a copy of this privacy notice - You may ask for a copy of this notice at any time, and you will be provided a copy promptly.
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 and make choices about your health information. This entity will make sure the person has this authority and can act for you before this entity takes any action.
File a complaint if you believe your privacy rights have been violated - You may report your complaint to this entity by contacting Shannon Francom, Ph.D., LMFT directly, or you may file a complaint with the U.S. Department of Health and Human Services Office, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
Your Choices For certain health information, you have choices in the way that this entity uses and shares information when it comes to:
Sharing information with family or others involved in your care, and
Providing mental health care.
This is done by giving written permission for this entity to share your information, in the form of a Release of Information (ROI). In the following cases, this entity never shares your information: for marketing purposes, the sale of your information, sharing of psychotherapy notes, or fundraising. *If you are not able to communicate your preference to this entity (for example, if you are unconscious), this entity may go ahead and share your information if it is believed it is in your best interest. This entity may also share your information when needed to lessen a serious and imminent threat to the health or safety of yourself or others.
Entity’s Uses and Disclosures This entity may use and share your information:
For Treatment - This entity may use your health information and share it with other professionals who are treating you, with your written permission, in the form of a Release of Information (ROI). Your protected health information may be used or disclosed to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that is involved in your care and treatment, and/or to other providers who may be involved in your care and treatment.
To Others Involved in Your Health Care - Unless you object, this entity may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, this entity may disclose such information as necessary if it is determined that it is in your best interest based on professional/clinical judgment. This entity may use or disclose protected health information to notify, or assist in notifying, a family member, personal representative, or any other person that is responsible for your care, of your general condition or death. If you are not present or not able to agree or object to the use or disclosure of the protected health information, then it will be determined whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
For the Practice Operations - This entity may use and share your health information to run the practice, improve your care, and contact you when necessary. Such instances include, but are not limited to: business planning and development, quality assessment, improvement medical review, legal services, auditing functions, education, provider credentialing, certification, underwriting, rating, other insurance-related activities, customer service, and compliance with privacy requirements.
For Payment/Billing of Your Services - Since payment for your care/treatment is completed directly by you, typically your health information will not be used/shared for any billing purposes. An exception to this is if/when you give permission for necessary information to be provided to your health insurance to assist you in obtaining reimbursement from them for services provided by this entity.
As Required by Law - This entity must make disclosures about you under federal and state laws, and when required by the Secretary of the Department of Health and Human Services, to investigate or determine compliance with the requirements of the Privacy Rule.
To Address Law Enforcement and Other Government Requests - This entity may disclose your protected health information for law enforcement purposes, with a law enforcement official, with health oversight agencies for activities authorized by law, or for special government functions such as military, national security, and presidential protective services.
In Cases of Abuse, Neglect, and/or Public Health and Safety Issues - This entity may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, your protected health information may be disclosed to the governmental entity or agency authorized to receive such information if it is suspected or believed that you have been a victim of abuse, neglect, or domestic violence, or if it is believed the reports will help prevent or reduce a serious threat to anyone’s health or safety. In this case, file disclosure will be made consistent with the requirements of applicable federal and state laws.
For Health Oversight - Your protected health information may be disclosed to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
In Response to Lawsuits and Legal Actions - Your protected health information may be disclosed in the course of any judicial or administrative proceedings or orders, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful processes.
This entity is required by law to maintain the privacy and security of your protected health information.
You will be promptly informed if a breach occurs that may have compromised the privacy or security of your information.
This entity must follow the duties and privacy practices described in this notice and give you a copy of it, if requested.
Your information will not be shared other than as described here unless you provide permission in writing. Once you provide permission to share your information, you may change your mind at any time, and should inform this entity in writing.
Changes to the Terms of this Notice The terms of this notice may be changed at any time, and the changes will apply to all information obtained about you. The new notice will be available upon request, in the office, and on the entity’s web site.