Full Privacy Statement

ANNE M. COLEMAN, MSW, LCSW
Notice of Privacy Policy

“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.”

I am committed to respecting and preserving the privacy and confidentiality of patient information. This Privacy Policy describes the personal information I collect, and how and when I use or disclose that information.

Understanding Your Health Record:
Each time you visit me a record of your visit is made. Typically, this record contains your mental health and medical history, current psychiatric symptoms, mental health assessment and test results, diagnoses, treatment and any plans for future care or treatment. The information contained in your record serves as a:
• Basis for planning your care and treatment,
• Means of communication among the health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided,
• A tool in educating health professionals,
• A source of data for medical research,
• A source of information for public health officials charged with improving the health of the nation,
• A source of data for facility planning and marketing, and
• A tool with which I can assess and continually work to improve the care I render and the outcomes I achieve.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Although your health record is my physical property, the information belongs to you. You have the right to:
• Request a restriction on certain uses and disclosures of your information,
• Obtain a paper copy of this Notice of Privacy Policy upon request,
• Inspect and obtain a copy of your health record,
• Request an amendment of your health record,
• Obtain an accounting of disclosures of your health information,
• Request communications of your health information by alternative means or at alternative locations, and
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

My Responsibilities:
• Maintaining the privacy and confidentiality of your health information,
• Providing you with a notice as to my legal duties and privacy practices with respect to information I collect and maintain about you,
• Abiding by the terms of this privacy policy,
• Notifying you if I am unable to agree to a requested restriction, and
• Accommodating reasonable requests you may have to communicate health information by alternative means or at alternative locations.

I reserve the right to change my privacy policy. Should my privacy policy change, I will mail a revised notice to the address you’ve supplied me and post the revised privacy policy in my office. I will not use or disclose your health information without your authorization, except as described below. I will also discontinue to use or to disclose your health information after I have received a written revocation of the authorization.

Examples of Uses and Disclosures of Health Information for Treatment, Payment, and Health Operations:
I will use your health information:
• For treatment purposes such as documenting all pertinent mental health and medical information, conducting differential diagnosis, determining the best course of treatment for you, and evaluating your progress in treatment.

I will disclose your health information:
• To your primary care physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you.
• To a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
• As required by law, such as disclosures about victims of abuse, neglect, or domestic violence; disclosures for judicial proceedings; and disclosures for law enforcement purposes.
• For payment purposes, such as sending a bill to you or a third party payer with health information that identifies you, as well as your diagnosis and the treatment procedures used.
• For purposes of evaluating and standardizing test instruments that may result in publication.
• To researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Patients involved in research at my practice would first read and sign an informed consent document.
• To my business associate, such as a medical billing company, so that they can perform the job I’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, I require the business associate to appropriately safeguard your information.
• To notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
• To provide appointment reminders or information about treatment alternatives or other healthrelated benefits and services that may be of interest to you.
• To the FDA and/or a Pharmaceutical Company, your health information relative to an experienced side effect to a prescribed medication that was previously unreported to enable product recalls or changes in reported side effects.
• To the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• As required by law, I may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
• For law enforcement purposes as required by law or in response to a valid subpoena.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that I have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

For More Information or to Report a Problem:
If you have questions and would like additional information, you may contact Anne M. Coleman, MSW, LCSW at (919) 360-0499.

If you believe your privacy rights have been violated, you can file a complaint with the Office for Civil Rights. Office for Civil Rights U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201

There will be no retaliation for filing a complaint.

NOTE: I will hand you a physical copy of this document at our apointment..