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THIS NOTICE
DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY ABE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our
commitment to your privacy
Our practice
is dedicated to maintaining the privacy of your personal health
information as part of providing professional care. We also are required
by law to keep your information private. These laws are complicated and
extensive, but we must give you this important information. This notice is
a condensed version of the full, legally required notice of privacy
practices (NPP) that you are welcome to read. It may be obtained by
requesting a copy from your therapist. We can’t cover all possible
situations here so please talk to our Privacy Officer (see end of this
notice) about any questions or problems about this policy.
We will use
the information about your health that we get from you or from others
mainly to provide you with treatment, to arrange payment for our services,
and for other business activities that are called, in the law, health care
operations. After you have read this brief NPP, we will ask you to sign a
“Consent Form” to let us use and share your information. Please be advised
that if you do not consent and sign this form, we cannot treat you.
If we or you
want to use or disclose (send, share, release) your information for any
other purposes, we will discuss this with you and ask you to sign an
“Authorization” form to allow this.
Of course, we
will keep your health information private but there are some times when
the laws require us to use or share it. Please refer to our “Contract for
Services” form under the subheading, “Confidentiality and Reporting Laws”
for more details.
Your rights regarding your health information
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You can ask us to communicate
with you about your health and related issues in a particular way or at a
certain place that is more private for you. For example, you can ask us to
call you at home, and not at work to schedule or cancel an appointment. We
will try our best to do as you ask.
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You have the right to ask us
to limit what we tell people involved in your care or the payment for your
care, such as family members and friends. While we don’t have to agree to
your request, if we do agree, we will keep our agreement except if it is
against the law, or in an emergency, or when the information is necessary
to treat you.
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You have the right to look at
health information we have about you such as your medical and billing
records.* You can even get a copy of these records but we may charge you.
Contact our Privacy Officer to arrange how to see your records. (See
below).
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If you believe the information
in our records is incorrect or missing important information, you can ask
us to make some kinds of changes (called amending) to your health
information. You have to make this request in writing and send it to our
Privacy Officer. You must tell us the reasons you want to make the
changes.
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You have the right to a copy
of this notice. If we change this NPP we will post the new version in our
waiting area and you can always get a copy of the NPP from the Privacy
Officer.
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You have the right to file a
complaint if you believe your privacy rights have been violated. You can
file a complaint with our Privacy Officer and with the Secretary of the
Department of Health and Human Services. All complaints must be in
writing. Filing a complaint will not change the health care we provide to
you in any way.
If you have
any questions regarding this notice or our health information privacy
policies, please contact our Privacy Officer who is Dr. Duane Kellogg, Jr.
He can be reached by phone at (207) 439-6994 or by mail at P.O. Box 269
Kittery, ME 03904.
The effective
date of this notice is September 1, 2003
* A summary
of your psychotherapy sessions can be provided by your therapist at an
additional charge.
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