NOTICE OF PRIVACY PRACTICES
Effective Date: January 3, 2025
Grace & Space Counseling
[Your Address]
La Crosse, WI 54601
[Your Phone Number]
breas@gspacecounseling.com
This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Access This Information.
YOUR PRIVACY IS IMPORTANT TO US
Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.
I am required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person.
1. Uses and Disclosures of PHI
I may use and disclose your PHI for the following purposes:
Treatment: To provide, coordinate, or manage your healthcare and related services, including consulting with other healthcare providers.
Payment: To obtain payment for services rendered, including contacting your insurance company for reimbursement.
Healthcare Operations: For business activities related to the provision of care, such as quality assessment and improvement, training programs, and administrative activities.
2. Other Uses and Disclosures
Your PHI may also be disclosed without your consent in certain situations, including:
Required by Law: If mandated by federal, state, or local laws.
Public Health Activities: To report disease or injury, or to notify authorities of suspected abuse or neglect.
Health Oversight Activities: For audits, investigations, or inspections by health oversight agencies.
Judicial and Administrative Proceedings: If required to comply with a court order or other legal process.
Emergency Situations: If necessary to prevent serious harm to yourself or others.
3. Your Rights
You have the following rights regarding your PHI:
Right to Inspect and Copy: You have the right to inspect and obtain a copy of your PHI.
Right to Amend: You have the right to request an amendment to your PHI if you believe it is incorrect or incomplete.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI.
Right to Confidential Communications: You have the right to request that communications regarding your PHI be conducted in a certain manner or at a specific location.
Right to an Accounting of Disclosures: You have the right to request a list of disclosures made of your PHI.
4. Complaints
If you believe your privacy rights have been violated, you may file a complaint with me or with the U.S. Department of Health and Human Services. You will not face retaliation for filing a complaint.
5. Changes to this Notice
I reserve the right to change this Notice at any time. Any changes will apply to PHI already in my possession and to any information I receive in the future. A copy of the current Notice will be available in my office and on my website.
6. Contact Information
For questions or to exercise your rights, please contact:
BethAnn Reas, LPC
Grace & Space Counseling
[Your Phone Number]
[Your Email Address]