Effective Date: August 1, 2024
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Integrative Psychiatry Center of Boulder, LLC (“IPC”) is required by federal and state laws to maintain the privacy of your health information. This HIPAA Notice of Privacy Practices (“Notice”) is posted at _____________.
IPC is also required to provide you with information about our privacy practices, our legal duties, and your rights concerning use and disclosure of certain individually identifiable health information – known as protected health information (“PHI”). PHI is the information we create and maintain while providing our services to you. Such information may include documentation of your symptoms or diagnoses, records and treatment protocols, and billing documents for those services. The federal privacy law, known as the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), guides our use and disclosure of your PHI for purposes of treatment, payment, and health care operations, including when we can use and disclose it with or without your written authorization.
Use and Disclosure Without Authorization
IPC may use and disclose PHI about you without authorization for the following purposes:
Treatment: When and as appropriate, IPC may use or disclose your PHI to facilitate your treatment. For example, we may disclose your PHI to a physician or other healthcare provider for the purpose of the provider’s treatment to you.
Payment: When and as appropriate, IPC may use and disclose your PHI to obtain payment for services we provide to you. For example, IPC may send bills to your educational institution or training program for payment on your behalf.
Healthcare Operations: When and as appropriate, IPC may use and disclose your PHI in connection with our healthcare operations. For example, healthcare operations include quality assessment and administrative improvement, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, legal services, and conducting training programs.
Required by Law: When and as appropriate, IPC may use or disclose your PHI when required to do so by federal, state, or local law.
Incidental Disclosures: When and as appropriate, IPC may disclose your PHI when a disclosure is an unavoidable by-product of other permitted uses or disclosures.
To You or Your Personal Representative: IPC must disclose your PHI to you, as described in this Notice.
Use and Disclosure With Authorization
IPC may only use and disclose PHI about you for the following purposes with your authorization as described as follows:
To You or Your Personal Representative: As discussed above, IPC must disclose your PHI to you, as described in this Notice. However, IPC may also disclose your PHI to your personal representative, but only if you agree that IPC may do so.
Persons Involved in Care: IPC may use or disclose PHI to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your PHI, IPC will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose PHI based on a determination using our professional judgment disclosing only PHI that is directly relevant to the person’s involvement in your healthcare.
Marketing Health-Related Services: IPC will not use your PHI for marketing communications without your written authorization. For the avoidance of doubt, this does not include notifications related to patient services, such as reminders of unscheduled or overdue care needs, or communications to you from your healthcare provider.
Appointment Reminders: IPC may use or disclose your PHI to provide you with appointment reminders (such as voicemail messages, email, texts, postcards, or letters), the form of which may be approved by you, as described below.
Disclosures Not Described Here: Any uses or disclosures of your PHI not described in this Notice will be made only with your written authorization, which you have the right to revoke at any time; provided, however, that you cannot revoke your authorization if IPC has already acted on it.
Your Rights Regarding PHI
Inspect or Copy: You have the right to look at or get copies of your PHI in a designated record set, with limited exceptions. You may request that we provide copies in a format other than photocopies. IPC will use the format you request unless we cannot practically do so. You must make a request in writing to the contact listed below at IPC to obtain access to your PHI. IPC will not charge you for the first set of your PHI; however, if you request copies, IPC will charge you $1.00 for each page and $15.00 per hour for staff time to copy your PHI, and postage if you want the copies mailed to you. If you request an alternative format, IPC will charge a cost-based fee for providing your PHI copies in that format. If you prefer, IPC will prepare a summary or an explanation of your PHI for a fee.
Disclosure Accounting: You have the right to receive a list of instances in which IPC or our business associates disclosed your PHI for purposes other than treatment, payment, healthcare operations, incidental permitted disclosures, where your authorization was provided, to family or friends involved in your care, for national security or intelligence purposes, as part of a limited data set where information disclosed excludes identifying information, or disclosures made to you about your own health information. Your request this list or accounting of disclosures, you must submit your request, which shall state a time period, which may not be longer than 6 years. Your request should indicate in what for you want the list (i.e. paper or electronic). If you request this list more than once in a 12-month period, IPC may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that IPC place restrictions or limitations on the use or disclosure of your PHI. In most cases we are not required to agree to certain restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of PHI to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which IPC has been paid out of pocket in full. To request restrictions, you must make your request in writing and must tell us what information you want to limit, whether you want to limit our use, disclosure, or both, and to whom you want the limits to apply.
Alternative Communication: You have the right to request in writing that IPC communicate with you about your PHI by alternative means or at alternative locations. Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that IPC amend your PHI. These amendments are typically to correct or amend information contained in your PHI. Your request must be in writing, and it must explain why the PHI should be amended. IPC may deny your request under certain circumstances.
Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on IPC’s website or by electronic mail.
Notifications, Questions and Complaints
Notifications: IPC is required by law to protect the privacy of your PHI. In the unlikely event of a disclosure or breach that compromises the privacy of your PHI, IPC will notify you and will follow the privacy practices as described in the HIPAA Notice of Privacy Practices for Protected Health Information and other law and implementing regulations. Any changes to this Notice will be provided electronically, on our website, and at any follow-up appointments.
Questions: If you would like more information about IPC’s privacy practices or have any questions or concerns, please don’t hesitate to contact us.
Complaints: If you think that we have not properly respected the privacy of your PHI, you are free to complain to us or to the U.S. Department of Health & Human Services, 1961 Stout Street, Room 1426, Denver, CO 80294, (303) 844-2024; (303) 844-3439 (TDD), (303) 844-2025 FAX. We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. If you want to complain to IPC directly, send a written complaint to us at the address or email shown below. If you prefer, you can discuss your complaint in person or by phone. The contact information of the individual at IPC responsible for handling inquiries and complaints regarding PHI is ____________________; address: 7102 La Vista Place, Suite 100, Longmont, Colorado 80503; e-mail: _______________; telephone: ___________________.
Acknowledgment
I acknowledge that I have received this HIPAA Notice of Privacy Practices (“Notice”) from Integrative Psychiatry Center of Boulder, LLC (“IPC”) and that I have been provided an opportunity to review it.
I understand that:
- I have certain rights to privacy regarding my protected health information (“PHI”);
- IPC can and will use my PHI for purposes of my treatment, payment for treatment, and health care operations;
- The Notice explains in detail how IPC may use and share my PHI for other purposes;
- I have the rights regarding my PHI listed in the Notice; and
- IPC has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting the individual listed in the Notice.
Signature: ________________________________
Printed Name: _____________________________
Date: ____________________________________