HIPAA Notice of Privacy Practice

Dr. Sonia Rubens, LLC

Tel: 312-820-5755

NOTICE OF PRIVACY PRACTICES

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

MY COMMITMENT TO YOUR PRIVACY

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. Applicable Federal and State laws require me to maintain the privacy of my patients’ personal and health information. This Notice explains my privacy practices, my legal duties, and your rights concerning your personal and health information. In this Notice, your personal or protected health information (PHI) is referred to as “health information” and includes information regarding your health care and treatment with identifiable factors such as your name, age, address, income or other financial information. I will follow the privacy practices described in this Notice while it is in effect. This Notice takes effect April 4, 2022 and will remain in effect until replaced.

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes, as long as you consent to receive evaluation or treatment services. To help clarify these terms, here are some definitions:

TREATMENT is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when a clinician consults with another health care provider, such as your family physician or another psychologist.

PAYMENT is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

HEALTH CARE OPERATIONS are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

USE applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

DISCLOSURE applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

I may use or disclose PHI for purposes outside treatment, payment, or healthcare operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, or healthcare operations, I will obtain an authorization from you before releasing this information. I will also need to obtain authorization from you before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joining, or family counseling session which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

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 (1) I relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. For workers’ compensation purposes. If you file a worker’s compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer, and the Division of Worker’s Compensation.

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

1. THE RIGHT TO REQUEST LIMITS ON USES AND DISCLOSURES OF YOUR PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. THE RIGHT TO REQUEST RESTRICTIONS FOR OUT-OF-POCKET EXPENSES PAID FOR IN FULL. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. THE RIGHT TO CHOOSE HOW I SEND PHI TO YOU. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests. I utilize HIPAA compliant email services for this practice (Hush Communications Canada, INC.) as well as a HIPAA compliant/HITRUST certified electronic health records system for records, appointment reminders, and credit/debit card payments (SimplePractice, LLC).

4. THE RIGHT TO SEE AND GET COPIES OF YOUR PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. THE RIGHT TO GET A LIST OF THE DISCLOSURES I HAVE MADE. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. THE RIGHT TO CORRECT OR UPDATE YOUR PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. THE RIGHT TO GET A PAPER OR ELECTRONIC COPY OF THIS NOTICE. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

QUESTIONS AND COMPLAINTS

For questions regarding this Notice or our privacy practices, or if you are concerned that your privacy rights may have been violated, you may contact me at Sonia@DrSoniaRubens.com. You may also make a written complaint to the U.S. Department of Health and Human Services whose address can be provided upon request. If you choose to make a complaint with us or the U.S. Department of Health and Human Services, I will not retaliate in any way.