Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

MY RESPONSIBILITIES:

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I have certain responsibilities and you have certain rights regarding the use and disclosure of your protected health information (“PHI”). In my private practice, I create a record of the care and services that you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. I am required by law to maintain the privacy and security of your PHI, to provide you with this Notice of Privacy Practices (“Notice”) stating my legal duties and privacy practices with respect to PHI, to follow the duties and practices described in the Notice currently in effect, and to promptly notify you in the event a breach occurs that may have compromised the privacy or security of your information.

This notice shall be effective October 1, 2022. I reserve the right to modify the terms of this Notice at any time and to make the new notice effective for all PHI that I maintain. Before I enact any important changes to my privacy practices, I will promptly revise this Notice and inform you of the changes. The new notice will be available upon request and on my website.

USES AND DISCLOSURES:

A. I may use and disclose your PHI without your prior written consent for the following reasons:

a. To provide, coordinate, or manage your psychological services and any related services. This includes coordination or management of psychological services with a third party who provides you with health care services or is involved in your care. For example, I may disclose your PHI to your primary care physician or your psychiatrist to ensure that they have the necessary information to diagnose or treat you.

b. To obtain payment for your psychological services. For example, I may disclose your PHI to your health insurance company to receive payment for the health care services that I have provided to you. I may also disclose your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims.

c. To support the health care operations of this practice. For example, I may use your PHI to contact you to schedule an appointment.

d. I am allowed or required to share your PHI in other ways without your authorization, including to comply with the law, to report a serious threat to your health or safety or the health and safety of another, to report suspicion of child abuse, elder abuse, or abuse of an individual with a disability, to contribute to public health and safety, to conduct research, to respond to lawsuits and legal proceedings, to address workers’ compensation, law enforcement, and other government requests, to work with a medical examiner or funeral director, and to respond to organ and tissue donation requests. By law, we must meet many conditions in connection with using or disclosing your information for these purposes. For more information, visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. For example, if you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

B. I will not use or disclose your PHI without your prior written consent for the following reasons:

a. Sharing psychotherapy notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is:

1. For my use in treating you.

2. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

3. For my use in defending myself in legal proceedings instituted by you.

4. For use by the Secretary of the Department of Health and Human Services (HHS) to investigate my compliance with HIPAA.

5. Required by law and the use or disclosure is limited to the requirements of such law.

6. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

7. Required by a coroner who is performing duties authorized by law.

8. Required to help avert a serious threat to the health and safety of others.

b. Marketing purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes without your prior written consent. I will never request a review from you. However, if you offer to provide one voluntarily for the purpose of allowing me to share the review publicly online or elsewhere to advertise my services or practice, I will provide you with a release form and HIPAA authorization. The HIPAA authorization is required in the instance that your review contains PHI (i.e., your name, the date of the service you received, the kind of treatment you are seeking or other personal health details). Because you may not realize which information you provide is considered “PHI,” I will send you a HIPAA authorization and request your signature regardless of the content of your review. Once you complete the HIPAA authorization, I will have the legal right to use your review for advertising and marketing purposes, even if it contains PHI. You may withdraw this consent at any time by submitting a written request to me via the email address I keep on file. Once I have received your written withdrawal of consent, I will remove your review from my website and from any other places where it may be posted. I cannot guarantee that others who may have copied your review from my website or from other locations will also remove the review. This is a risk that I want you to be aware of, should you give me permission to post your review.

c. Sale of your PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

d. I will not use or disclose your PHI other than as described in this Notice, unless you provide me prior written authorization. If you choose to sign an authorization to disclose your PHI, you may later revoke this authorization at any time in writing to stop any future uses and disclosures of your PHI by me (to the extent that I have not taken action in reliance on the permitted use or disclosure indicated of such authorization).

C. You have the right and choice to tell me what and how PHI is shared for the following reasons:

a. Disclosures to family, friends, or others. You have the right and choice to tell me that I may provide your PHI to a family member, friend, or other person whom you indicate is involved in your care or the payment for your health care, or to share your PHI in a disaster relief situation. The opportunity to consent may be obtained retroactively in emergency situations, for example if you are unconscious or to mitigate a serious and immediate threat to health or safety.

YOUR RIGHTS:

1. The right to request limits on uses and disclosures of your PHI. You have the right to ask me not to use or share certain health information for treatment, payment, or health care operations. I will consider your request but I am not legally required to agree to your request. I may say “no” if I believe it would affect your health care. You may not limit the uses and disclosures that I am legally allowed or required to make. If you pay for a health care service or item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or health care operations with your health insurer. I will say “yes” unless a law requires me to share that information.

2. The right to see and obtain copies of your PHI. In most cases and to the extent permissible by law, you have the right to look at or obtain electronic or paper copies of PHI that I have about you. You will need to make the request in writing and I will provide you with a copy of your record, or if you agree, a summary of it, within 30 days of receiving your written request. I may charge a reasonable, cost-based fee for doing so.

3. The right to choose how I contact you or send PHI to you. You have the right to ask that I contact you in a specific way (for example, cell phone instead of home phone) or that I send information to you at an alternate address (for example, your work address instead of your home address) or by alternate means (for example, e-mail instead of regular mail). I will say “yes” to all reasonable requests.

4. The right to amend your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. You will need to make the request in writing. I may say “no” to your request, but I will state the reason for denial in writing within 60 days of receiving your request.

5. The right to obtain a list of the disclosures I have made. You have the right to request an accounting of the times I have shared your PHI, who I shared it with, and why. You will need to make the request in writing. I will include all disclosures except for those made for the purposes of treatment, payment, or health care operations, or for which you have already provided me with written authorization. The list will include disclosures made within the six years prior to the date of your request unless you request a shorter time. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

6. The right to obtain a copy of this Notice. You have the right to obtain a paper copy or electronic copy via e-mail of this Notice at any time. Even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

7. The right to choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights or make choices about your health information. I will verify that the person has this authority and can act for you before I take any action.

8. The right to file a complaint. If you think that I have violated your privacy rights, you may file a complaint with me by emailing drwang@synrisewellness.com, or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue S.W., Washington, D.C. 20201; calling 1-877-696-6775; or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. I will not retaliate against you for filing a complaint.