THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. THE PRIVACY OF YOUR CHILD’S BEHAVIORAL HEALTH INFORMATION IS IMPORTANT TO US.

If you have any questions about this Notice or would like to file a privacy related complaint, please contact our Privacy Officer: compliance@tillytherapy.com

Our Legal Duty:
You may request a copy of our notice (or any subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed in this notice.

Uses and Disclosures of Protected Health Information: We will use and disclose your child’s protected health information about you for treatment, payment, and health care operations. Following are examples of the types of uses and disclosures of your child’s protected health care information that may occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

• Treatment: We will use and disclose your child’s protected health information to provide, coordinate or manage your child’s behavioral healthcare and any related services. This includes the coordination or management of your child’s behavioral healthcare with a third party. We will also disclose protected health information to other physicians or healthcare providers who may be treating you. For example, your child’s protected health information may be provided to a physician or healthcare provider to whom you have been referred to ensure that the physician or healthcare provider has the necessary information to diagnose or treat you.

• Payment: Your child’s protected health information will be used, as needed, to obtain payment for your child’s health care services. This may include certain activities that your child’s health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for protected health necessity, and undertaking utilization review activities.

• Health Care Operations: We may use or disclose, as needed, your child’s protected health information in order to conduct certain business and operational activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet where you will be asked to sign your child’s name. We may use or disclose your child’s protected health information, as necessary, to contact you by telephone or mail to remind you of your child’s appointment. We will share your child’s protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your child’s protected health information, we will have a written contract that contains terms that will protect the privacy of your child’s protected health information.

• Uses and Disclosures Based on your Written Authorization: Other uses and disclosures of your child’s protected health information will be made only with your authorization, unless otherwise permitted or required by law as described below. You may give us written authorization to use your child’s protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your child’s authorization while it was in effect. Without your written authorization, we will not disclose your child’s health care information except as described in this notice.
  Others involved in your child’s Health Care: Unless you object, we may disclose to a member of your child’s family, a relative, a close friend or any other person you identify, your child’s protected health information that directly relates to that person’s involvement in your child’s health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your child’s best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying an authorized family member, personal representative or any other person that is responsible for your child’s care of your child’s location or general condition.

• Public Health and Safety: We may disclose your child’s protected health information to the extent necessary to avert a serious and imminent threat to your child’s health or safety, or the health or safety of others. We may disclose your child’s protected health information to a government agency authorized to oversee the health care system or government programs or its contractors, and to public health authorities for public health purposes.

• Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

• Abuse or Neglect: We may disclose your child’s protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your child’s protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

• Food and Drug Administration: We may disclose your child’s protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations; to track products; to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.

• Criminal Activity: Consistent with applicable federal and state laws, we may disclose your child’s protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

• Required by Law: We may use or disclose your child’s protected health information when we are required to do so by law. For example, we must disclose your child’s protected health information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws. We may disclose your child’s protected health information when authorized by worker’s compensation or similar laws.
  Process and Proceedings: We may disclose your child’s protected health information in response to a court or administrative order, subpoena, discovery request or other lawful processes, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, we may disclose your child’s protected health information to law enforcement officials.

• Law Enforcement: We may disclose limited information to a law enforcement official concerning the protected health information of a suspect, fugitive, material witness, crime victim or missing person. We may disclose the protected health information of an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances. We may disclose protected health information where necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.

  Client Rights

• Access: You have the right to look at or get copies of your child’s protected health information, with limited exceptions. You must make a request in writing to the contact person listed herein to obtain access to your child’s protected health information. You may also request access by sending us a letter to the address contained in this notice. If you request copies, we will charge you the statutory allowed rate for each page.

• Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your child’s protected health information for purposes other than treatment, payment, health care operations and certain other activities. The accounting will be provided for the past six (6) years. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your child’s protected health information, a description of the protected health information we disclosed, the reason for the disclosure, and certain other information. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

• Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your child’s protected health information. We are not required under the law to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is so memorialized in writing.

• Confidential Communication: You have the right to request that we communicate with you in confidence about your child’s protected health information by alternative means or to an alternative location. You must make your child’s request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to bill and collect payment from you.

• Amendment: You have the right to request that we amend your child’s protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want to be amended or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted to be amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people or entities you name, of the amendment and to include the changes in any future disclosures of that information.

• Electronic Notice: If you receive this notice on our website or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.

• Questions and Complaints: If you want more information about our privacy practices or have questions or concerns, please contact us using the information contained herein. If you believe that we may have violated your child’s privacy rights, or you disagree with a decision we made about access to your child’s protected health information or in response to a request you made, you may complain to us using the contact information below.
  
  

  You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your child’s complaint with the U.S. Department of Health and Human Services upon request.