Mountain Pine Counseling PLLC
Susan Crowder, LCPC, LMHC, BC-TMH
2604 Tradewinds Way
Thompson Falls, MT 59873
406-201-6248
susan.crowder@counselingmail.com
This notice was revised on 06/25/2024
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
– Ensure that protected health information (“PHI”) that identifies you is kept private to the best of my ability. – Give you this notice of my legal duties and privacy practices with respect to health information. – Follow the terms of the notice that is currently in effect.
– I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
HOW I MAY USE AND DISCLOSE YOUR HEALTH INFORMATION: As a health care provider, I use and sometimes disclose your PHI for the purposes of treatment (for example to coordinate your care with another provider), payment(verify eligibility and submit claims) and for health care operations(for example quality assurance and improvement activities). Except as outlined below, I will not use or disclose your protected health information for any other purpose or to anyone else unless you have given me your authorization to do so. You may give me authorization to disclose your health information to anyone whom you designate. Your authorization must be in writing, using my Release of Information form designating what information may be released and to whom it may be released. You may revoke an authorization at any time but a revocation will not affect any use or disclosure permitted by the authorization while it was in effect.
Your PHI related to substance use disorder treatment is protected by additional Federal laws and regulations which provide a higher level of protection in some circumstances. For example, under these laws, Mountain Pine Counseling may not say to a person outside Mountain Pine Counseling that you attend the program, nor may Mountain Pine Counseling disclose any information identifying you as an alcohol or drug abuser, or disclose any
other protected information except as permitted by federal law. Other exceptions to permitted uses and disclosures of information related to substance use are indicated in the following section in this notice.
Uses or Disclosure of Your Protected Health Information Permitted or Required Without Your Authorization:
When required by law. For example, I may disclose PHI when a law requires me to report certain information, or in response to a court order provided that certain regulatory requirements are met. I may also disclose PHI as required or permitted by law to report suspected abuse or neglect of a vulnerable individual or population and as required by authorities that monitor compliance with privacy laws.
In a medical emergency. I may disclose PHI to medical personnel in cases of medical emergency. To avert threats to health or safety. In order to avoid a serious threat to health or safety, I may disclose PHI to law enforcement in certain situations such as when a threat is made to commit a crime on the premises or against provider.
For research. I may disclose your information for scientific research if certain requirements are met. Working with Business Associates. PHI may be disclosed to a qualified service organization or business associate who may perform various functions on our behalf or provide certain types of services such as legal counsel and my electronic health records system vendor. Agreements with such parties subject them to the same legal requirements
regarding the protection of your PHI.
Relating to decedents. I may disclose certain information to coroners, medical examiners and/or funeral directors as consistent with the law.
Public Health / Health Oversight: I may disclose PHI as required to public health authorities and to a health oversight agency for activities authorized by law such as audits, investigations, inspections and licensure. Treatment and Payment. I may use and disclose your PHI for treatment and payment purposes (described in the second paragraph of this notice). This does not apply to disclosures of Substance Use Disorder specific treatment information, which requires your authorization.
Military and Special Government Functions. If you are a member of the armed forces I may release information as required by military command authorities. I may also disclose information to Correctional Institutions or for national security purposes. This does not apply to disclosures of Substance Use Disorder specific treatment information, which requires your authorization.
Unless you object, I may also disclose your health information that is relevant to a family member, relative, close personal friend or any other person identified by you who is involved in your health care or payment related to your health care. This does not apply to disclosures of Substance Use Disorder specific treatment information, which requires your authorization.
Disclosures of Your Protected Health Information that Require Your Authorization:
I will ask for your written authorization before I use or disclose your protected health information for any purpose other than those describe above. For example, I would require your authorization for the use or disclosure of psychotherapy notes in most cases (please note that progress notes are not considered psychotherapy notes). I would also require your authorization for uses or disclosures for certain types of marketing activities and any disclosure that constitutes a sale of health information.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding your health information:
Right to Inspect and Copy. In most cases, you have the right to inspect and obtain a copy of your health information that I maintain in a designated record set. Usually, this includes health information that is used to make decisions about your care, as well as billing records, but does not include psychotherapy notes or information compiled for use in civil, criminal or administrative proceedings, or in other limited circumstances. You must submit your request in writing using my access request form, and I may charge a fee to cover the cost associated with providing you with a copy. In addition, I may deny your request to inspect and copy your information in certain limited circumstances.
Right to Amend. If you believe that health information I have about you is incorrect or incomplete, you may ask me to amend that information for as long as the information is kept by me. To request an amendment your request must be made in writing using our amendment request form. I may deny your request if, for example, I determine that your information is accurate and complete, or if the information was not created by me or is not part of the designated record set.
Right to Request Restrictions. You have the right to request a restriction or limitation on certain uses and disclosures of your health information. Mountain Pine Counseling is not required to agree to restrictions you request except under certain circumstances, but if it does agree, then it is bound by that agreement and may not use or disclose any information you have restricted, except as necessary in a medical emergency. Your request must be in writing and
contain: the information you want to limit, whether you are requesting a limitation in the use or disclosure of your information, or both, and to whom you want the limitation applied.
Right to an Accounting of Disclosures. You have the right to request a list of disclosures of your health information made by Mountain Pine Counseling. I are not required to provide an accounting of disclosures made to you, disclosures made pursuant to your authorization or certain other disclosures otherwise permitted or required by law (for example, disclosures made for the purposes of treatment, payment or healthcare operations). Your request must be submitted in writing and must specify a time period which may not exceed six years. The first list you request within a 12-month time period will be free; I may charge a fee for additional lists requested within the same 12-
month period.
Right to Choose How I Contact You. You have the right to request that I communicate with you in a certain way or at a certain location. For example, you may request that I contact you only by phone or mail or email and only at work or at home. These requests must be in writing to the address below. I will accommodate any reasonable requests.
Right to a Paper Copy of this Notice. You also have the right to receive a paper copy of this notice at any time.
Right to be Notified of a Breach. You have the right to be notified if a breach occurs that may have compromised the privacy or security of your information.
QUESTIONS AND COMPLAINTS
You may contact Mountain Pine Counseling if you have a question about this Notice. You may also find more information at: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. You may file a complaint with Mountain Pine Counseling or with the Department of Health and Human Services, Office for Civil Rights if you believe your privacy rights have been violated. Violating these regulations is a crime; violations are reportable to the appropriate authorities. You will not be penalized for filing a complaint. To ask a question or file a complaint with Mountain Pine Counseling submit your question or complaint in writing to:
Mountain Pine Counseling
PO Box 803
Thompson Falls, MT 59873
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.
BY SIGNING BELOW I AM AGREEING THAT I HAVE RECEIVED A COPY OF THE HIPAA NOTICE OF PRIVACY PRACTICES AND THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THE DOCUMENT.