NOTICE of PRIVACY PRACTICES and the NO SURPRISE ACT

 This Notice is being provided to you by the staff at Integrative Psychology Group, LLC shoe provide services or fulfill administrative duties in the clinic. All providers and staff are required by law to maintain the privacy of your Protected Health Information (PHI), including PHI that we keep in electronic form (ePHI). This Notice will help explain to you how we maintain your records, among other things. We are also required to inform you of our legal obligations and how this impacts the privacy protections for your health information.

PROTECTED HEALTH INFORMATION (PHI) is any documentation that identifies you; relates to your past, present or future mental health needs; relates to the care provided; or relates to the past, present or future payment for your care. PHI typically includes your symptoms, diagnoses, the treatment provided to you, information that may be provided about you by others who have been involved in your care, and billing and payment information relating to your care. PHI may come in traditional paper form or be kept and communicated in electronic form, referred to as ePHI. Examples of ePHI include any records we keep on the computer and/or on cloud based programs. This Notice applies to both formats.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT YOUR PERMISION :

A record of your treatment is maintained confidentially. Your written permission is required to disclose any information in your record to a third party in almost all situations. Providers may use or disclose PHI/ePHI without your authorization in the following circumstances:

• There are limits on our confidentiality when you or other persons are in physical danger:
  • If I come to believe that you are threatening serious harm to another person, I am required to try to protect that person.
  • If you seriously threaten, or act in a way that is very likely to harm yourself, I may have to seek a hospital for you, or to call on your family members or others who can help protect you.
  • In an emergency where your life or health is in danger, and I cannot get your consent, I may give another professional some information to protect your life.
  • If I believe or suspect that you are abusing a child, an elderly person, or a disabled person I must file a report with a state agency.
• We may occasionally consult with other health and mental health professionals about your case. If so we make every effort to avoid revealing your identity. These professionals are legally also legally bound to keep the information confidential.
• If you are involved in a court proceeding and there is a request concerning the services provided you we will seek your written authorization prior to disclosing any information. If disclosure is contraindicated a court order may be needed to protect your records.

f. Please bear in mind that I if you should decide to instigate any legal proceedings against me for any reason I will no longer be able to guarantee confidentiality.

• Should you elect to use insurance benefits to pay for a psychological assessment or psychotherapy your insurance company has the rights to information about your diagnosis, symptoms, history and substance abuse issues (if any). We can provide no assurance that the confidentiality of your information will be maintained.
• Joint Activities and Your Treatment: Your PHI may be used and shared by the Providers to further their joint activities and with other individuals or organizations that engage in your treatment, payment or healthcare operational activities with the Providers.
• To Contact You: Your PHI may be used to call you or send you a letter about your care, for appointment reminders if you choose that service, to provide you with treatment options, or to advise you about other health-related benefits and services.
• For Payment Purposes: We may use your PHI/ePHI to prepare claims to your insurance company. We will include information that identifies you, as well as your diagnosis, dates and types of service provided, and any payments you have made.
• When Required by Law: We may use or disclose your health information when required by law. If this happens, disclosures will be made in compliance with the law and will be limited to the relevant requirements of the law. Examples include law enforcement reports, abuse and neglect reports, military command authorities, and reports to coroners and medical examiners in connection with death. The Providers must also comply with the Secretary of the Department of Health and Human Services for the purpose of investigating or determining its compliance with the requirements of the Privacy Rule.
• For Healthcare Operations/Oversight: The Providers may disclose your PHI to a health oversight agency, such as a government agency, for activities authorized by law, such as for professional licensure and for healthcare operations, such as seeking reimbursement from an insurance company.
• Business Associates: Your PHI may be used by Providers and disclosed to individuals or organizations that assist the Providers with their legal obligations as described in the Notice. For example, we may disclose information to consultants or attorneys who assist us in our business activities. Business Associates also contract with the Providers to assist in business operations, such as

Health information is shared when necessary to provide clinical care services and to secure payment for services provided. Examples of such disclosures include letting your psychiatrist know about your response to prescribed mental health medications and communicating between Providers about shared clients, such as in family counseling.

billing and administrative support. These business associates are required to protect the confidentiality of your information with administrative, technical and physical safeguards. § Workers Compensation: If you file a worker’s compensation claim, with certain exceptions, your therapist must make available, at any stage of the proceedings, all mental health information in his/her possession relevant to that particular injury in the opinion of the Delaware Department of Vocational rehabilitation, to your employer, your representative, or other state department upon request.

USES AND DISCLOSURE WHEN YOU HAVE THE RIGHT TO OBJECT

• Disclosure to and Notification of Family, Friends or Others: Unless you object, Providers may use their professional judgment to provide relevant protected health information to your family member, friend, or another person. This person would be someone that you indicate has an active interest in your care or the payment for your mental health care or who may need to notify others about your location (for example, for transportation purposes) or general condition.
• Clinical Notes: Notes recorded by your Provider documenting the contents of a counseling session and your care are part of your PHI. These will not be disclosed without your consent, unless for purposes already explained herein. For example, you must authorize the release of your record to your attorney, to a life insurance company, to your employer, the military, or your school. You may revoke any such authorization at any time, provided the request is made in writing.

YOUR INDIVIDUAL RIGHTS ABOUT PATIENT HEALTH INFORMATION

Your Specific Rights are listed below: § Right to request restrictions: You have the right to request in writing that we not use or disclose your information for treatment, payment, and/or operational activities except when authorized by you, when required by law, or in emergency circumstances. We are not legally required to agree to your request. After you make your request to BPS, we will provide you with written notice of our decision about your request.

• Right to request nondisclosure to health plans for services that are self-pay: You have the right to request in writing that services for which you self-pay for in full in advance of your visit not be disclosed to your health plan.
• Right to receive confidential communications: 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 a therapist. Upon your request, your therapist or this office will send your bills to another address.) To request confidential communications, you must make your request in writing to the address above and specify how or where you wish to be contacted. We will grant all reasonable requests. § Right to inspect and receive copies: In most cases, you have the right to inspect and obtain copies of PHI in your therapist’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your Provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your Provider will discuss with you the details of the request and denial process. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
• Right to request an amendment to your record: If you believe that information in your record is incorrect or that important information is missing, you have the right to request in writing that your Provider amend your PHI for as long as the PHI is maintained in the record. In your request, you must give a reason for the amendment. We are not required to agree to your request but a copy of your request will be added to your record.
• Right to know about disclosures: You have the right to receive a list of instances when disclosures of your PHI have been made. Certain disclosures will not be included, such as disclosures for your treatment, billing, other healthcare operations, or when you have authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free of charge. Any additional request within the same calendar year requires a processing fee.
• Right to make complaints: If you are concerned that we have violated your privacy, or you disagree with a decision we made about access to your records, you may file a complaint with the entity that provided the services to you. Or, you may file a complaint with Integrative Psychology Group, LLC. You will not retaliated against for filing a complaint. If you believe that your privacy rights have been violated, you may also contact the US Department of Health and Human Services, Office for Civil Rights. You can get the address of the local office from us.

Office for Civil Rights

US Department of Health and Human Services

Office of the Secretary

200 Independence Avenue,

S.W.Washington, D.C. 20201

Tel: (202) 619-0257Toll Free: 1-877-696-6775 http://www.hhs.gov/ContactUs.html

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE  MEDICAL BILLS

(OMB Control Number: 0938-1401)

When you get emergency care, or get treated by an out-of-network provider at an in-network or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see an in-network doctor or other health care provider, you may owe certain out-of-pocket costs,     such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between   what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount can be more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is  your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

 If you get other services at these in-network facilities, out-of-network providers can’t balance  bill you unless you give written consent and give up your protections.

 You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

 When balance billing isn’t allowed, you also have the following  protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

Cover emergency services without requiring you to get approval for services in advance (prior authorization).

Cover emergency services by out-of-network providers.

Base what you owe the provider or facility (cost-sharing) on what it would pay an  in-network provider or facility and show that amount in your explanation of benefits.

Count any amount you pay for emergency services, or out-of-network services  toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact: The Delaware Board of Professional Regulations at (302) 739-4522

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.