This form serves to demonstrate the nature of your personal information usage while receiving services from Music Plus - Therapy Services of Boulder LLC.
At Music Plus - Therapy Services of Boulder, LLC we are committed to protecting your privacy. Because we respect your privacy, we ask that you please read this important Notice. It concerns the privacy of your health information when you use the services of Music Plus - Therapy Services, LLC. We recommend that you keep a copy of this Notice for future reference. At Music Plus Therapy Services of Boulder, LLC we are committed to protecting client confidentiality to the full extent of the law. The information below (which we are required by law to give to you) reflects federal regulations that set a minimum standard of privacy.
This Notice explains our privacy practices and describes how Music Plus - Therapy Services of Boulder, LLC may use and disclose your health information that specifically identifies you or could be used to identify you (your "health information"). This Notice also provides you with important information about your privacy rights and how you may exercise those rights. Please note that others involved in your health care (for example, your health plan, physicians, etc.) may send you separate notices describing their privacy practices.
Your health information: To provide you with safe and convenient music therapy services, we need to obtain and use some health information. Without your health information, we would be unable to provide our services. Examples of the health information we hold include your therapy records, your health plan information, your services payment history, and your address. This information may come from you (for example, when you tell us about your medical and/or psychosocial history), your physician, and your health plan and its agents.
Treatment: We are permitted to use and disclose your health information to provide you with appropriate treatment. We may use or disclose your health information to:Review and interpret your treatment planContact your treating physician to resolve questions about your therapyNotify you of any issues or scheduling problems with your therapy
Payment: We are permitted to use and disclose your health information to receive payment for our services. We may:Bill you for your therapy, Contact your health plan or its agents to check your co-payment amount, Check to see if music therapy services are covered under your plan, Provide your health plan or its agents with the health information they need to pay us for the services we provide, and so that they may otherwise manage your health benefit
Healthcare operations: We are permitted to use and disclose your health information for the general administrative and business activities necessary for us to operate as a provider of therapeutic services. We may:Review and evaluate the performance of our therapists, Conduct audits and compliance programs, Collect medical and psychosocial history information from you, Send communications informing you of the status of your therapy Provide customer service, Review and resolve grievances. Music Plus - Therapy Services of Boulder, LLC may also share health information with: You: We are permitted to disclose your health information to you. For example, we may inform you of the status and progress of your therapy. In addition, 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 to you.
Family members and others involved in your care: In certain circumstances, we are permitted to disclose your health information to family members or other people involved in your care but only if he or she is able to be properly identified and authenticated and only if you have provided permission to in advance. This is done for the convenience of you and your family, so that the people close to you may continue to be involved in your care. If for any reason you do not want us to disclose your health information to your family members, you have the right to request a restriction as provided below in Your Privacy Rights.
Service vendors: At times, we must provide your health information to outside companies so that they may help us operate more efficiently. For example, we may provide your name, address, and other health information to a company that helps us mail important health communications to you. These companies perform their duties at our direction, within strict guidelines established by the HIPAA Privacy Standards. All of these companies are required to protect your health information and use it only for authorized purposes.
Courts and government bodies: In certain circumstances, federal and state laws may require us to disclose your health information. We may also provide information to government agencies for healthcare- related investigations, audits, or inspections; to comply with workers' compensation laws; or for certain national security or intelligence activities. If you are involved in a legal matter, we may be ordered to provide your health information to a court or other party. In those cases, only the specific health information required by law, subpoena, or court order will be disclosed.
Public health and safety entities: We are also permitted to disclose your health information for certain purposes that have been determined to benefit the public as a whole. For example, we may disclose your health information to the Food and Drug Administration, to your local public health department, or to law enforcement agencies if the disclosure will prevent or control disease, or prevent a serious threat to the health and safety of an individual or the public.
The Department of Health and Human Services: We are required to disclose your health information to the Department of Health and Human Services, at its request, so it may investigate complaints and review our compliance with the HIPAA PrivacyStandards.
Child Abuse: If your therapist, in the ordinary course of professional practice, has reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had non-accidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then your therapist must report this suspicion or belief to the appropriate authority.
Adult and Domestic Abuse: If your therapist knows or in good faith suspects that an elderly individual or an individual who is disabled or incompetent has been abused, the appropriate information as permitted by law may be disclosed.
Health Oversight Activities: If the Professional Board of Examiners is investigating your therapist, the board may subpoena records relevant to such investigation.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and will not be released without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If your therapist believes in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, the appropriate information, as permitted by law, may be disclosed.
Worker’s Compensation: Workman’s Comp may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work- related injuries or illness without regard to fault.
For other purposes: We must obtain your written authorization if we want to use or disclose your health information for activities other than those listed above. If we need your authorization for certain activities, we will contact you. You may revoke your authorization at any time in writing.
Your privacy rights: Music Plus - Therapy Services of Boulder, LLC is committed to complying with the HIPAA Privacy Standards while providing you with all the information you need to make informed decisions about your health care and therapy. The following describes your privacy rights under the HIPAA Privacy Standards:The right to request your "designated record set": You may request a copy of your health information maintained by.The right to request amendments to your designated record set: You may request changes to the information contained in your designated record set. However, we are not required to honor your request if, for example, the information you want to amend is accurate and complete. When requesting an amendment, you must provide a reason to support your request.The right to request an "accounting of disclosures": You may request a list or accounting of the non-routine disclosures of your health information that we have made. Examples may include disclosures to a court or government agency, to a public health and safety entity, for research, or to the Department of Health and Human Services. You may receive one accounting per year free of charge. For additional requests within a one-year period, we may impose a reasonable fee.The right to request a copy of this Notice: You may request a copy of this Notice at any time.The right to request restrictions: You may request restrictions on how we use and disclose your health information, and whether we disclose your health information to family members or others involved in your care. Although Music Plus - Therapy Services of Boulder, LLC is not required to agree to your restriction requests, we will try to honor your request to block health information from your family members. If Music Plus - Therapy Services of Boulder, LLC agrees to your restriction request, it is important to understand that your family members will no longer be able to act on your behalf or continue to be involved in your care, which may make our services less convenient for you and your family.The right to request "confidential communications" of your health information: You may request that we send your health information to an address that is different than your family address (for example, your work address). Communications containing your health information will be sent to you at the address indicated. However, please note that certain billing information related to your therapy may continue to be mailed to the person with financial responsibility if that is someone other than you. If your request this confidential handling of your health information, it is important to understand that your family members will no longer be able to act on your behalf or continue to be involved in your care, which may make our services less convenient for you and your family. To exercise any of your privacy rights, please put your request in writing and mail it to Music Plus - Therapy Services of Boulder, LLC at 8120 Sheridan Blvd B-100 Arvada 80003. To ensure the accuracy of your report, the request must include the following information:your name, full address
Additional rights: Some states may provide additional privacy protections under existing or future state laws. We are committed to complying with applicable laws when we use or disclose your health information.
Music Plus - Therapy Services of Boulder, LLC's Responsibilities: We are required by the HIPAA Privacy Standards to maintain the privacy and security of your health information. We must obey all of the applicable conditions of the HIPAA Privacy Standards and only use and disclose your health information as allowed by law. We are required to provide you with this Notice and to abide by the privacy practices outlined in this Notice. We reserve the right to change a privacy practice described in this Notice and to make the new privacy practice effective for all health information that we maintain. If we need to make a material change to this Notice, you will receive a new Notice by mail, email, or other means permitted by the HIPAA Privacy Standards.Protecting your health informationBecause protecting your health information is important to us, we have taken steps that protect your health information from unauthorized uses and disclosures. We restrict access to your health information to those members of the Music Plus - Therapy Services of Boulder, LLC workforce who need this information to continue providing the therapeutic services that you need. We make your privacy a priority. To that end, we have trained and educated members of our workforce about the meaning and requirements of our privacy practices and their role in complying with the HIPAA Privacy Standards.Privacy complaintsIf you have any concerns about our privacy practices, or if you feel your privacy rights have been compromised, you have the right to file a complaint with Music Plus - Therapy Services - LLC, or with the United States Department of Health and Human Services. Please be assured that if you file a privacy complaint, your complaint will be handled in a professional manner, and you will not be subject to any type of penalty for filing the complaint.
Questions? At Music Plus - Therapy Services of Boulder LLC, we want to make it easy for you to make informed healthcare decisions. If you have any questions about this Notice or our privacy practices as they relate to your music therapy services, you may call Music Plus - Therapy Services of Boulder, LLC at (720) 456-0401.This Notice is effective Jan 1, 2016
Client/Patient FAQs About The HIPAA Notice of Privacy Practices: What does HIPAA stand for? HIPAA is an acronym for Health Insurance Portability & Accountability Act which was passed by Congress in 1996 and effective as of April 14, 2003. Why should I sign now? Signing now simply lets us know you received the HIPAA Notice of Privacy Practices. Of course you can choose not to sign. What happens if I don't sign this acknowledgement form? First, you need to know we will provide you timely care and treatment whether or not you sign the form. Second, if you choose not to sign the form, we will note your choice on the bottom of the acknowledgement form and hope you take a copy of the Notice. Is my signature just acknowledging receipt of this notice? Yes. By signing this acknowledgement form we then can show the Department of Health & Human Services that we are complying with one of the major rules of HIPAA to make sure we give every patient the opportunity to have our Notice. Are you doing anything differently with my health information now than you did before HIPAA? Actually, we are going to guard your medical information even more closely and will make certain your medical information is shared only with those needing your information for treatment, payment, or healthcare operations. After I sign this acknowledgement form, then what happens? We will place your form in your record. What am I going to be paying out because of signing? Signing our HIPAA Privacy Notice acknowledgement form has NO bearing on your current payment arrangement
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