Notice of Privacy Practices
EFFECTIVE DATE: January 1, 2023
WHEN IT COMES TO YOUR HEALTH INFORMATION, YOU HAVE CERTAIN RIGHTS. THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Each time you receive health care services from Blueprint Integrative Mental Health, LLC (“Blueprint Integrative Mental Health”) a record of your treatment is made. This record contains demographic information about your mental health symptoms, examinations, test results, medications you take, and the plan for your care. We refer to this information as your health or medical record. It is an essential part of the healthcare we provide for you. Your health record contains personal health information (“PHI”) and there are state and federal laws to protect the privacy of your health information. This notice is required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
Each client who is given a copy of the Notice of Privacy Practices will also be asked to sign the “Acknowledgement of Receipt” of such notice.
Your Rights
Get an electronic or paper copy of your medical record
• You can ask to see or get 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 copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home, office phone, or email) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will validate the documents against state law and ensure that the person has the authority to act on your behalf before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, 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 your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written authorization or approval :
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
Other Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways:
Treat you
• We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
• We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
We may share your health information with our business associates so they can perform the job we have asked them to do. To protect your PHI, we have written contracts with our business associates requiring them to safeguard your information.
Bill for your services
• We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
Our Uses and Disclosures
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
We may disclose information required by law to the following entities or type of entities that includes, but is not limited to:
Food and Drug Administration
Public Health or legal authorities charged with disease prevention
Correctional institutions
Workers’ compensation agents
Organ and tissue donation organization
Military command authorities
Health oversight agencies
Medicare or Medicaid if requested for an audit or investigation
Funeral directors, coroners, and medical examiners
National security and intelligence agencies
Protective services for the president and others
Law enforcement as required by law or in accordance with a valid subpoena
Licensing boards
To avoid a serious threat to the health and safety of a person or the public
Special Rules for Disclosure of Psychiatric, Substance Abuse, and HIV-Related Information:
For disclosures of health information about psychiatric conditions, substance abuse, or HIV-related testing and treatment, special rules may apply. In general, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your permission or a court order. There are exceptions to this general rule. For example, HIV test results may be disclosed to your provider of health care without written authorization.
Our Responsibilities
• 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. You may revoke or change your mind at any time. Let us know in writing if you change your mind. We will notify you in writing if we are unable to agree to the requested restriction.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. If material changes are made, then the new notice will be distributed and available upon request, and posted on our website.
This Notice of Privacy Practices applies to the following organizations:
Blueprint Integrative Mental Health, LLC
377 Riverside Drive Suite 302, Franklin, TN 37064