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Notice of Attendance and Privacy PDF 2-06-19
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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.

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) is a federal program that requires that all medical records and other  individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally are kept properly  confidential. This Act applies to all health care providers, it is intended to standardize health care information as well as ensure privacy and security  of patient information. As a result of this act, this business would like to advise you of how we will protect the privacy of your or your child’s  medical record.

As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we  may use and disclose your health information.

If you sign a consent form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and health  care operations

Treatment means providing, coordinating or managing health care and related services by one or more health care providers.  An  example of this would be disclosure of your Protected Health Information (PHI) to providers outside this business such as your outside  case manager, treatment team members, doctors, nurses and other health care providers in connection with your health care treatment.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization  review. An example for this would be telling your health plan about treatment you are going to receive to determine whether your plan  will pay for the treatment.

Health Care Operations includes the business aspects of running our practice, such as conducting quality assessment and improvement  activities, auditing functions, cost-management analysis and customer services. For example, we may also disclose PHI to doctors, nurses,  therapists, students and other health care personnel for teaching purposes.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

Legal Authority to make health care decisions for minors or others Usually, the health information rights described in this Notice may be given to  a person with legal authority to make health care decisions for a child or other person (for example, a parent of legal guardian). There are  exceptions. For example, in New Mexico some health care services can be provided to a minor without the consent of a parent, guardian or other  person. In these cases, the minor has the rights described in this Notice for health information related to the health care service provided.

We may without prior consent use or disclose protected health information to carry out treatment, payment or health care operations in the  following circumstances:

In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after delivery of such  treatment;

If we attempt to obtain your consent but are unable to do so due to substantial barrier so communicating with you and we determine  that in our professional judgment, your consent to receive treatment is clearly inferred from circumstances.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services  that may be of interest of you.  

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are  required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to our  Privacy Officer or your therapist.

The right to request restrictions on certain uses and disclosers of PHI including those related to disclosures to family members, close  personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree  to a restriction, we must abide by it unless you agree in writing to remove it.  

The right to reasonable requests to receive confidential communication of PHI from us by alternative means or at alternative locations.  The right to inspect and copy your PHI.

The right to amend your PHI

The right to receive an accounting of disclosures of PHI.

The right to obtain a paper of this notice from us upon request.


Research as a professional medically based therapeutic center, we may use and disclose PHI about you for research purposes. We will  only use and disclose your information for a research project if we obtain your permission or if the need to obtain your permission has  been waived by a designated review committee that meets Federal requirements.

Dogwood Therapy Services Inc.


Promotional Communications this business does not share or sell your PHI to companies that market health care products or services  directly to consumers. This business may maintain mailing lists of individuals for promotional materials and news about this company or  therapy ideas. These include our newsletter and other information of this nature. You may be included on these lists. This business may  send information about its programs and services to the individuals on these lists. If you wish to be removed from the mailing lists please  send writing notice to this business at 1111 Alameda Blvd. NW, Albuq., NM 87114

To Avert a Serious Threat to Health or Safety we may use and disclose PHI about you when necessary to prevent a serious threat to your  health and safety or the health and safety of others. Disclosure will only be to persons who could help prevent the threat. To Have Supervised Students Providing Care this business’s prides itself for remaining on the cutting edge of providing therapy. One of  the ways we maintain this status is by arrangements with Universities across the country that train therapists.  We have students  observing or doing rotations at this business that last from a few days to 16 weeks. These students are generally outstanding and many of  them have been hired by this business after they complete their University Degree Program. Students are supervised by our therapists  according to the requirements of their professional standards and the University Program. If you object to having a student involved  in  your therapy, please send written notice to this business at: Dogwood Therapy Services 1111 Alameda Blvd. NW, Albuquerque, NM  87114.

To Have Your Picture Taken we have taken pictures of clients to use in therapy sessions, use in publications to demonstrates specific  therapy approaches, for training clients, family caregivers and this business’s staff. We require written permission for photographing or  videotaping a client or session prior to doing so. If you change your mind and decide that you no longer want our business to take images,  we would like writing permission sent to Dogwood Therapy Services, 1111 Alameda Blvd. NW, Albuq., NM 87114.  However, any images  that this business had taken prior to this decision remain property of our business and we shall continue to use them.


Military we may disclose your PHI as required by military command authorities if you are in the armed services. Workers Compensation We may disclose your PHI for workers’ compensation or similar programs to the extent necessary to comply with  laws relating to workers’ compensation or other similar programs established by law. These programs provide benefits for work-related  injuries or illness.

Public Health Risks as required by law, we may disclose your PHI for public health activities. For example, we may undertake these  activities:

o To prevent or control disease, injury or disability;

o To report child abuse or neglect,

o To notify a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or  condition,

o To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic  violence. We will only make this disclosure subject to certain requirements when mandated or authorized by law; and  o To notify an individual that a client tells that they are intending harm, neglect or abuse in order to protect both at person and  our client.

Lawsuit’s and Disputes if you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative  order. We may also disclose PHI about you in response to a subpoena, discovery request or other lawful process

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practice with respect to  PHI.

This notice was effective as of April 14, 2003 and revised January 7, 2006 and we are required to abide by the terms of the notice of Privacy  Practices and to make the new notice provisions effective for all PHI that we maintain. We will post this notice and you may request a written copy  of a revised Notice of Privacy Practices from our office. If you want more information about HIPAA or believe your privacy rights have been  violated, contact one or both of the following departments:

Therapy Offices of: Dogwood Therapy Services Inc

3108 Alamogordo DR NW, Albuquerque, NM 87120-1108    505-228-4650


Office of Civil Rights; US Department of Health and Human Services

1301 Young Street, Suite 1169 200 Independence Avenue SW

Dallas, TX 75202 Washington, DC 20201

Phone (214) 767-4056   FAX (214)767-0432  TDD (214)767-8940 Toll free:1-877-696-6775

Please provide as much information as possible so your complaint may be properly investigated.

You will not be penalized for filling a complaint.

Dogwood Therapy Services Inc.


Attendance Policy (Keep for Your Records)

Due do an increase in the number of clients wishing to receive services, it is necessary to institute an attendance policy.   The policy is as follows:

1. Extended Absences-These are client absences that are due to sickness, injury, vacation, etc.  We require  notification of the absences as soon as possible.  Continued therapy will be rescheduled when the client is ready  to begin services again.  The therapy time slot cannot be guaranteed.

2. Absences-No more than three (3) absences per quarter will be allowed.  Prior notification is required (e.g.  parent call to cancel the session).  The therapist and client/caregiver/parent will reevaluate scheduling (e.g.,  change in therapy time), transportation issues, etc. to determine the cause of excessive absences and make  efforts to correct the situation if possible.  If absences continue to persist, the client will be dropped from the  caseload.

3. No Shows- A “NO SHOW” is when there is no prior notification of an absence. No more than three (3) no shows  per quarter will be allowed.  You will be dropped from the schedule and placed on a waiting list to continue  serviced.  There is no guarantee of continuing with the same time slot.  You will be notified that you have been  dropped from the caseload and it will be your responsibility to call when you are ready to implement services  again.

4.  In the event that a client is late, the therapist is required to wait only 15 minutes before canceling. It is the  responsibility of the client or caregiver to call and schedule a make-up session if available.  

Transportation is the responsibility of the participant or family. For participants requiring alternative forms of  transportation, be sure to use a reliable service.  Absences or late drop offs due to transportation problems may still be  considered absences.

There will be a $30 cancelation fee charged for appointments that are not attended, unless the office is notified 24  hours in advance.  

Dogwood Therapy Services Inc.