KRISTIN BOWERS, MA, LPC-S

YOUR PROTECTED INFORMATION MAY BE USED AND DISCLOSED

PAYMENT: Your protected health information will be used as needed. For example, obtaining approval for a hospital stay or residential treatment program may require that any relevant be disclosed to your health insurance company to obtain approval for the admission.

TREATMENT: With a ROI (release of information form), One In Mind will use and disclose your protected health information to provide, coordinate, or manage your health care treatment and related services. For example, your protected health information may be provided to a doctor or treatment team member to whom you have been referred to ensure that the doctor or treatment team member has the necessary information to diagnose or treat you.

BUSINESS ASSOCIATES: One In Mind may use or disclose your protected health information with third party "business associates" that perform various activities (e.g. billing services). If ever an arrangement between a business associate and One In Mind involves the use or disclosure of your protected health information, we will have a written contract from them that contains terms that will protect the privacy of your protected health information.

WRITTEN AUTHORIZATION: With a ROI (release of information form), uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

OPPORTUNITY TO OBJECT: You have the opportunity to object. If you are not present or able to object, then your provider may, using professional judgment, determine whether the disclosure is in your best interest.

OTHERS INVOLVED IN YOUR HEALTHCARE: Unless you object and with a ROI, One In Mind may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that relates to that person's involvement in your health care.

EMERGENCIES: In an emergency situation, your provider shall try to provide you a Notice of Privacy as soon as reasonably practical after the delivery of treatment.

WITHOUT AUTHORIZATION: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
• Right To Inspect and Copy your protected health information. However, I may refuse to provide access to certain psychotherapy notes or information for a civil or criminal proceeding.
• Right to Amend. You may request an amendment of protected health information about you. If I deny your request for amendment, you have the right to file a statement of disagree with me and your medical record will note the disputed information.
• Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures that I may have made for purposes other than treatment, payment or healthcare operation. It excludes disclosures I may have made to you, for a facility director, to family members or friends involved in your care, or for notification purposes
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your protected health information for treatment, payment, or health care operations. We are not required to agree to your request.
• Right to Request Confidential Communication. You have the right to request that I communicate with you about your health information in a certain way or at a certain location. I may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address of other method of contact.
• Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS
If you believe that I have violated your privacy rights, you have the right to file a complaint in writing with me or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington D.C. 20201 or by calling (202) 619-0257. You may file a complaint without fear of retaliation.

The passage of the federal "medical records privacy law" known as HIPAA (Health Insurance Portability and Accountability Act) requires that I give you a copy of this document and to secure your signature indicating you have received a copy of it. Laws such as these are important, but also complex and in my Notification of Patient Rights document I have tried to inform you about your rights in plain, simple language. Please read the contract and do not hesitate to ask me about any questions you might have about its content.

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:
Suspected child abuse or dependent adult or elder abuse, for which One In Mind is required by law to report this to the appropriate authorities immediately.

If a client is threatening serious bodily harm to another person/s, One In Mind must notify the police and inform the intended victim.

If a client intends to harm himself or herself, One In Mind will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, we will take further measures without their permission that are provided by law in order to ensure their safety.