Notice of Privacy Practices This notice describes how we use and disclose your protected health information. Please read it carefully.



Your Rights The information that you share with us is important and you have certain rights when it comes to having access to it. This section explains your rights and some of our responsibilities to help you.

Your Right

How We Can Help

Access to an electronic or printed copy of your medical record.

You can ask for an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Correct medical record.

If you believe that our medical record for you is incorrect, you can ask us to correct the information by making a written request. If we are unable to do this, we will provide a written explanation within 60 days.

Confidential communications.

If you have concerns about the confidentiality of communication channels such as email, we will contact you in whatever reasonable way you deem most appropriate.

Ask us to limit what we use or share.

If you are using insurance benefits to pay for services, we may not be able to withhold certain types of information, but will reasonably consider your request. If you are paying out-of-pocket and in full, we will not share information with your insurer unless there is a law that requires us to do so.

Get a list of the people with whom We will provide a list, at your request, of any entities with whom we have shared we have shared your information. your information for the past year and why the information was shared. We can provide one such list for free each year. Additional requests may incur a reasonable, cost-based fee. Get a copy of this notice.

You can receive a paper or electronic copy of this notice at any time.

Have someone else act on your behalf.

If you have a legal guardian or have granted someone medical power of attorney, that person can make choices about your care. We will make sure that person is legally authorized to act for you before we take any action.

File a complaint if your feel your rights are violated.

You can complain if you feel we have violated your rights by contacting us by phone or email. You may also file a complaint with the US Department of Health and Human Services Officer for Civil Rights: By Mail: 200 Independence Avenue, S.W., Washington, D.C. 20201; By Phone: 1-877-696-6775; Online: www.hhs.gov/ ocr/privacy/hipaa/complaints/.

Yetman Counseling Services 1140-B2 Sam Newell Road • Matthews, NC • 28105

704-284-9096

http://yetmancounselingservices.com

Your Choices In some situations, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with family, friends, or others

• Share information with other agencies or individuals involved in your care

• Share information in a disaster relief situation

In these cases, we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In these cases, we may be legally or ethically required to share your information:

• Situations where you tell us you are planning to serious hurt yourself or another person

• If a judge specifically requests we share certain information

• If, in a medical emergency, information we have might be helpful for your treatment

How We Use Your Information We typically use your information in the following ways.

To treat you.

We might use your information when consulting with other employees about your treatment.

To run our practice.

We use your information to improve the way we provide care or to contact you when necessary.

To bill you for services.

We can use your information in order to receive payment from insurance companies or other entities.

For other purposes.

We sometimes use your information for less common purposes, like responding to legal requests, to facilitate research, during audits conducted by the Department of Health and Human Services.

Our Responsibilities In working together, we have important responsibilities when it comes to ensuring the safety and security of your health information.

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

• If we change the details of this notice, we will let you know and will provide you with an updated notice upon request.

Yetman Counseling Services 1140-B2 Sam Newell Road • Matthews, NC • 28105

704-284-9096

http://yetmancounselingservices.com

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