Claudelle R. Glasgow, Psy.D., LLC

Licensed Psychologist

2143 NE Broadway, #6 Portland, OR 97232

www.claudelleglasgow.com

 

 

NOTICE OF PRIVACY PRACTICES

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

 

PLEASE REVIEW IT CAREFULLY.

 

LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about my privacy practices, my legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice goes into effect September 1, 2014 and will remain in effect until we replace it.

 

We reserve the right to change my privacy practices and the terms of this Notice at any time provided such changes are permitted by applicable law. We reserve the right to make changes in my privacy practices and the new terms of this Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

 

You may request a copy our 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 at the end of this Notice.

 

 

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION

Treatment: We may use health information about you to provide you with treatment and services. We may disclose this information to a health care provider involved in your care, such as a physician.

 

Electronic Communications & Telehealth: We may use electronic communication (i.e., internet, email, Zoom, eTherapy, GotoMeeting, etc) to communicate with you or to other authorized individuals you designate to be involved in your care.  You understand that reasonable accommodations are made to insure the privacy of documents or communications via internet, but there is no guarantee and in signing do not hold the provider liable for breaches in security.

 

Payment: We may use and disclose your health information to obtain payment for services we provide for you. This may include providing your diagnoses and treatment to your health insurance plan.

 

Health Care Operations: We may use and disclose your health information for operational purposes. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

 

Individuals Involved in Care: We may disclose your health information to a family member, friend, or other person identified by you if they are involved in your care or with payments related to your care. We may also use or disclose health information about you to notify those persons of your location, general condition, or death. You have the opportunity to object, in writing, to such uses or disclosures. In the event of an emergency, we will utilize our professional judgment to disclose only health information that is directly relevant to the person’s involvement in your health care.

 

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

 

 

Required by Law: We may use or disclose your health information when we are required to do so by law.

 

Public Health: We may use or disclose your health information for public health activities that serve to prevent a threat to the health and safety of a person or the general public or to control for communicable disease.

 

Abuse, Neglect, or Domestic Violence: We may disclose your health information to appropriate authorities if we reasonably believe that you are a victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or to the health or safety of others.

 

Legal Activities: We may disclose your medical information in response to a court proceeding. We may also disclose information about you in response to a subpoena or other legal process.

 

National Security, Military, Inmates: We may disclose to authorized federal officials your health information required for national security and intelligence activities. We may disclose to military authorities the health information of Armed Forces personnel. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate.

 

Research: We may disclose your medical information to researchers under certain limited circumstances.

 

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

 

Your Authorization: In addition to the above-mentioned uses, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You may also cancel an authorization at any time, in writing. Your cancellation will not affect any prior uses or disclosures permitted while your authorization was in effect. Other uses and disclosures will be made only with your written authorization.

 

 

YOUR PATIENT RIGHTS

Access to Health Information: You have the right to inspect or obtain copies of your health information, with limited exceptions. You must submit this request in writing. We may charge you a reasonable fee for the costs of copies, summaries or explanations of your health information, or mailings of this requested information. Your request may be denied under certain limited circumstances. If denied, we will inform you in writing and you may be able to request a review of this denial.

 

Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your health information, known as an accounting. The accounting may be for up to six (6) years prior to the date on which you request the accounting, but not before January 1, 2012. We are not required to include disclosures for treatment, payment, or health care operations or certain other exceptions. You must submit this request for an accounting in writing. You are entitled to one free accounting in any twelve (12) month period, but we may charge you a reasonable fee for additional accounting requests.

 

Restrictions: You have the right to request, in writing, that we place additional restrictions on my use or disclosure of your health information, including that related to treatment, payment, or individual involvement.  We are not required to agree to these requests, but if we do, we must keep to our agreement, except in an emergency.

 

Confidential Communication: You have the right to ask that we communicate with you in a certain manner or at a certain location. You must make this request in writing. We must agree to your request if it is reasonable.

 

Amendments: You have the right to request that we amend your health information. If you believe any information in your record is incorrect or any important information is missing, you must submit your amendment request in writing. Your request may be denied under certain limited circumstances. If denied, we will inform you in writing and you may be able to request a review of this denial.

 

Notice: You have the right to request and get a paper copy of this Notice and any revisions made to this Notice.

QUESTIONS AND COMPLAINTS

If you have any questions or want more information about this Notice of Privacy Practices, please contact me at:

 

Claudelle R. Glasgow, Psy.D., LLC

2143 NE Broadway St, #6

Portland, OR 97232

Telephone: (312) 804 - 3079

E-mail: drcrglasgow@gmail.com

 

 

You also have the right to complain to us and to the United States Secretary of Health and Human Services if you are concerned about our use and disclosure of your health information or that we may have violated your privacy rights. There is no risk in filing a complaint.

 

To file a complaint with me, please contact me at:

 

Claudelle R. Glasgow, Psy.D., LLC

2143 NE Broadway St, #6

Portland, OR 97232

Telephone: (312) 804 - 3079

E-mail: drcrglasgow@gmail.com

 

To file a complaint with the United States Secretary of Health and Human Service, please contact at:

 

Office of Civil Rights

U.S. Department of Health and Human Services

200 Independence Ave., SW

Washington, D.C. 20201

 

 

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(cut and retain with client’s records)

 

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 

We have read, understand, and received a copy of the Notice of Privacy Practices HIPAA.

 

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Client’s Name [Print]

 

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