Notice of Privacy Practices
This notice tells you how I'm making use of your health information, how I might disclose your health information to others, and how you can get access to the same information.
Please review this notice carefully and feel free to ask for clarification about anything in this material you might not understand. The privacy of your health information is very important to me and I want to do everything possible to protect that privacy.
We have a legal responsibility under the laws of the United States and the state of Georgia to keep your health information private. Part of my responsibility is to give you this notice about my privacy practices. Another part of my responsibility is to follow the practices in this notice. This notice takes effect on April 14, 2003 and will be in effect until it is replaced. I have the right to change any of these privacy practices as long as those changes are permitted or required by law. Any changes in my privacy practices will affect how I protect the privacy of your health information. This includes health information I will receive about you and that I create here. These changes could also affect how I protect the privacy of any of your health information I had before the changes.
When I make any of this changes, I will also change this notice and give you a copy of the new notice. When you are finished reading this notice, please take it with you at no charge. If you request a copy of this notice at any time in the future, I will give you a copy at no charge to you. If you have any questions or concerns about the material in this document; please ask me for assistance and I will provide assistance at no charge to you.
Here are some examples of how I use and disclose information about your health information. I may use or disclose your health information...
- 1. To your physician or other health-care provider who is also treating you with your written authorization.
- 2. To any person required by federal, state, or local laws to have access to your treatment program.
- 3. To receive payment from a third party payer for services I provide for you.
- 4. To anyone you give me written authorization to have your health information for any reason you want. You may revoke authorization in writing any time you want. When you revoke authorization it will only affect your health information from that point on.
- 5. To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, I will give you an opportunity to object. If you object, or are not present, or are incapable of responding, and I use my professional judgment, in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In doing so, I will only use or disclose the aspects of your health information that are necessary to respond to the emergency.
- 6. To appropriate authorities under Georgia Law in the following circumstances: Imminent Danger to you or others, Child Abuse or under Court Order.
As a client, you have these important rights:
- A. With limited exceptions, you can make a written request to inspect your health information that is maintained by me for my use.
- B. You can ask me for photocopies of the information in part "A" above.
- C. I will charge you $.10 per page for making these photocopies.
- D. You have a right to a copy of this notice at no charge.
- E. You can make a written request to have me communicate with you about your health information by alternative means, at an alternative location (an example would be if your primary language is not spoken by Ms. Baltimore, and I am treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.
- F. You can make a written request that I place other restrictions on the ways I use or disclose your health information. I may deny any or all of your requested restrictions. But if I agree to those restrictions, I will abide by them in all situations except those that in my professional judgment constitute an emergency.
- G. You can make a written request that I amend the information in part "A" above.
- H. If I approve your written amendment, I will change our records accordingly. I will also notify anyone else whom they have received this information, and anyone else of your choosing.
- I. If I deny your amendment, you can produce a written statement in my records disagreeing with my denial of your request.
- J. You may make any written request that I provide you with a list of those occasions where I or my business associates disclosed your health information for purposes other than treatment, payment, or my business operations. This can go back as far as six years, but not before April 14th, 2003.
- K. If you request the accounting in "J" above more than once in a twelve-month period I may charge you based on our actual cost of tabulating these disclosures.
- L. If you believe I have violated any of your privacy rights, are you disagree with a decision I have made about any of your rights in this notice, you may complain in writing to:
Compliance Officer: PEGGY S. BALTIMORE LCSW, ACSW
Board Certified Diplomate in Clinical Social Work
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
- M. You may also submit a written complaint to the United States Department of Health and Human Services. I will provide you with an address upon written request.
Peggy S. Baltimore LCSW
Certified Child Psychotherapist
Counseling & Supervision Services
2901 University Avenue
Columbus, GA 31907