Policies and Practices to Protect the Privacy of Your Health Information
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Effective/Last Revised Date: July 29, 2013
We Are Back on Track LLC is required by law to protect the privacy of your health information in the context of your mental health and substance abuse health care administered by this agency. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.
The terms "information" or "health information" in this notice include any personal information that is created or received by a health care provider that relates to your physical or mental health or condition, the provision of health care to you, or the payment for such health care.
We have the right to change our privacy practices. If we do, we will provide the revised notice to you within 60 days by direct mail or post it in our agency office or on the website.
We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
◦"PHI" or Protected Health Information refers to information in your health record that could identify you.
◦"Treatment, Payment and Health Care Operations"
Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another therapist. Another example would be when we release your treatment plan to your insurance company and/or to your primary care physician.
Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
◦"Use" applies only to activities within our office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
◦"Disclosure" applies to activities outside of our office such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We must use and disclose your health information to provide information:
◦To you or someone who has the legal right to act for you (your personal representative);
◦To the Secretary of the U.S. Department of Health and Human Services, if necessary, to ensure that your privacy is protected; and Where required by law.
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes we have made about your conversation during a private, group, joint, or family counseling session,
*For Research Purposes such as research related to the prevention of disease or disability, if the research study meets all privacy law requirements.
◦To Provide Information regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
◦For Organ Procurement Purposes. We may use or disclose information for procurement, banking or transplantation of organs, eyes or tissue.
◦If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is our intent to meet the requirements of the more stringent law.
If none of the above reasons applies, then we will obtain your written authorization to use or disclose your health information. If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is our intent to meet the requirements of the more stringent law. In some states, your authorization may also be required for disclosure of your health information. In many states, your authorization may be required in order for us to disclose your highly confidential health information, as described below. Once you have given us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization, except if we have already acted based upon your authorization. To revoke an authorization, contact the phone number listed below on this notice.
Federal and applicable state laws require special privacy protections for highly confidential information about you. "Highly confidential information" may include confidential information under Federal law governing alcohol and drug abuse information as well as state laws that often protect the following types of information:
1.HIV/AIDS status
2.Mental health
3.Genetic tests
4.Alcohol and drug abuse
5.Sexually transmitted diseases and reproductive health information
6.Child or adult abuse or neglect, including sexual assault
IV. Patient’s Rights and Therapist’s Duties
Patient’s Rights:
◦Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
◦Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing therapists. On your request, we will send your bills to another address.)
◦Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. Your therapist may also deny access to your Psychotherapy Notes.
◦Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
◦Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.
◦Right to a Paper Copy: You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
Therapist’s Duties:
◦We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
◦We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
◦If we revise these policies and procedures, we will notify you by mail or on your next session. You may obtain a copy of this notice at the local office or our website.
V. Complaints
◦Contacting We Are Back on Track, LLC. If you have any questions about this notice or want to exercise any of your rights, please call 770-468-3326. Please specify that your question or concern is in reference to your mental health and/or substance abuse protected health information.
◦Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:
Compliance Department – Privacy Complaints
We Are Back on Track LLC
354 Senoia Road
Peachtree City, GA 30269
You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any adverse action against you for filing a complaint.
VI. Cancellation Policy
If you give less than 24 hours advance notice for cancellation, you will incur a $55 fee. If you miss an appointment without giving any notice at all, you will be charged the full session amount as a "no show" fee. In the event of a verifiable emergency, you will not be charged for session cancellation.
VII. Financial Responsibility
We Are Back on Track LLC can assist you in completing and filing any insurance forms, which may be utilized for payments for services; however, you maintain full responsibility for paying all charges for services rendered. You will need to provide all required insurance information when checking in for services and you will need to update any changed insurance information immediately upon the date of change. All co-payments and unsatisfied deductibles are to be paid at the time of services rendered. Back on Track LLC accepts payment by cash, check or credit/debit card.
VIII. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on September 1, 2011. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.
IX. Patient’s Consent

I consent for my therapist to disclose my protected health information (PHI) as required by my insurance company. Furthermore, if my insurance company requires coordination of care with my Primary Care Provider (PCP), I consent for my therapist to disclose my protected health information to my PCP. I have read this statement of Back on Track LLC practices and policies and I both understand and approve of its content.

I agree and consent that the use of a key board, mouse or other electronic device in submitting this information to We Are Back on Track LLC constitutes my signature, acceptance, and agreement to the content of the e-signed documents, as if actually signed by me in writing. Any electronic document bearing a user’s e-signature will be considered "in writing" and "wet-signed". Any user e-signed document shall be deemed to be an “original” document when printed and used in the normal course of business. * *
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