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BY: Hanna Rue, PhD, BCBA-D
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INFORMATION AND RESEARCH
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices applies to Autism Spectrum Therapies, LLC and its subsidiaries (“AST,” “we,” “our” or“us”). We are required by law to maintain the privacy of protected health information (“PHI”) and to provide patients with notice of ourlegal duties and privacy practices with respect to protecting your PHI. We are required to abide by the terms of this Notice of PrivacyPractices (“Notice”) (or other notice in effect at the time of the use or disclosure). We reserve the right to change the terms of thisNotice as necessary and to make the new Notice effective for all PHI maintained by us. If we change this Notice, we will post the newnotice at http://autismtherapies.com/hipaa.php or a copy may be obtained by mailing a request to Attention: Privacy Officer,Autism Spectrum Therapies, 2550 North Hollywood Way, Suite 102, Burbank, CA 91505.
WE KEEP A RECORD OF THE HEALTH CARE SERVICES WE PROVIDE YOU. YOU MAY ASK US TO SEE AND COPY THATRECORD. YOU MAY ALSO ASK US TO CORRECT THAT RECORD. WE WILL NOT DISCLOSE YOUR RECORD TO OTHERSUNLESS YOU DIRECT US TO DO SO OR UNLESS THE LAW AUTHORIZES OR COMPELS US TO DO SO. YOU MAY SEE YOURRECORD OR GET MORE INFORMATION ABOUT IT BY CONTACTING AST’S PRIVACY OFFICER AT THE ADDRESS LISTEDABOVE.USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Except for the allowed and required uses and disclosures described in this Notice, we will use and disclose your health information onlywith written authorization from you. This includes, except for limited circumstances allowed by federal privacy laws, not using ordisclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information forcertain promotional communications that are prohibited marketing communications under federal law, without your writtenauthorization.Once you authorize us to release your health information, we cannot guarantee that the recipient we gave the information to isobligated to protect and will not further disclose your information. You may take back or “revoke” your written authorization at anytime in writing. This will not apply to uses and disclosures we have already acted upon based on your initial authorization. To find outhow to take back your authorization, see our contact information in the section called “Exercising Your Rights.”
Uses and Disclosures for Treatment.
We use and disclose your PHI to provide treatment and other services to you--for example, to provide our services or to consult withspecialists about your healthcare. We may use your information to direct or recommend alternative treatments, therapies, health careproviders, or settings of care to you or to describe a health-related product or service. We may also disclose PHI to other providersinvolved in your treatment.
Uses and Disclosures for Payment.
We may use and disclose of your PHI as necessary for payment purposes of those health professionals and facilities that have treatedyou or provided services to you. For example, we may forward information regarding services provided to your insurance company toarrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the personresponsible for your payment.
Uses and Disclosures for Health Care Operations.
We may use and disclose your PHI for our health care operations, which include internal administration and planning and variousactivities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluatethe quality and competence of our services and other health care professionals. We may disclose PHI to our performance improvementteam in order to resolve any complaints you may have and ensure that you our satisfied with our services.
Family and Friends Involved In Your Care.
With your approval, we may from time to time disclose your PHI to designated family, friends and others who are involved in your careor in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you areunavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your bestinterest, we may share limited PHI with such individuals without your approval.
Certain aspects and components of our services are performed through contracts with outside persons or organizations, such asauditing, accreditation, vendors, legal services, etc. At times, it may be necessary for us to provide certain of your PHI to one or moreof these outside persons or organizations who assist us with our health care operations. In all cases, we require these businessassociates to appropriately safeguard the privacy of your PHI.
Other Uses and Disclosures.
We are permitted or required by law to make certain other uses and disclosures of your PHI without your consent or authorization.
• We may use and disclose your PHI when required to do so by any applicable federal, state or local law;
• We may release your PHI for public health activities, such as required reporting of disease, injury, and birth and death and forrequired public health investigations;
• We may release your PHI as required by law if we suspect child abuse or neglect;
• We may also release your PHI as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
• We may release your PHI to the Food and Drug Administration if necessary to report adverse events, product defects, or toparticipate in product recalls;
• We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’compensation or other similar programs.;• We may release your PHI if required by law to a government oversight agency conducting audits, investigations, or civil or criminalproceedings;
• We may release your PHI if required to do so by a court or administrative ordered subpoena or discovery request;
• We may release your PHI to law enforcement officials as required by law to report wounds and injuries and crimes;
• We may release your PHI to coroners and/or funeral directors consistent with law;
• We may release your PHI if necessary to arrange an organ or tissue donation from you or a transplant for you;
• We may release your PHI for certain research purposes when such research is approved by an institutional review board withestablished rules to ensure privacy;
• We may release your PHI in limited instances if we suspect a serious threat to health or safety;
• We may release your PHI if you are a member of the military as required by armed forces services; we may also release your PHIif necessary for national security or intelligence activities; and
• We may release your PHI to workers' compensation agencies if necessary for your workers' compensation benefit determination.Some state laws limit the sharing of information listed above. For example, there are special laws that protection information aboutHIV/AIDS status, mental health care, development disabilities, and drug and alcohol abuse care. We will obey these laws.
YOUR PRIVACY RIGHTS
Access to Your PHI.
You have the right to copy and/or inspect much of the PHI that we retain on your behalf. All requests for access must be made inwriting and signed by you or your representative. If we maintain your PHI in electronic form, you may request to receive a copy inelectronic form. AST will charge you a reasonable cost-based fee in accordance with HIPAA and applicable state law.
Amendments to Your PHI.
You have the right to request in writing that PHI that we maintain about you be amended or corrected. We are not obligated to makeall requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us,must be in writing, signed by you or your representative and must state the reasons for the amendment/correction request. If wemake an amendment or correction you request, we may also notify others who work with us and have copies of the uncorrected recordif we believe that such notification is necessary.
Accounting for Disclosures of Your PHI.
You have the right to receive an accounting of certain disclosures made by us of your PHI. Requests must be made in writing andsigned by you or your representative. The first accounting in any 12-month period is free; you will be charged a reasonable sum basedon a set fee for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of PHI.
You have the right to request restrictions on certain of our uses and disclosures of your PHI for treatment, payment, or health careoperations.We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate andwe retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination byus, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction.Notwithstanding the foregoing, we must agree to your request to restrict disclosure of your PHI to a health plan if the disclosure is forthe purpose of carrying out payment or health care operations and is not otherwise required by law, the disclosure is not otherwiserequired by law, and the PHI pertains solely to a health care item or service for which you or another person other than the health planhas paid us in full.
You have the right to ask to receive confidential communications by asking us to send information by alternative means or atalternative locations — for example, to another address instead of your home address. You must make a written request to receiveconfidential communications or to cancel or change an earlier request. Please see the section called “Making a Written Request” forinstructions. We will honor reasonable requests.
Secure Retention and Disposal of Your PHIWe safeguard your PHI throughout our collection, use, and disclosure of that PHI in a manner consistent with applicable laws andregulations. Your PHI will be retained by in accordance with applicable laws and regulations, and then will be disposed of securely.
Notification of BreachIn the event of a breach of the security of your PHI, we will provide you with a notification about the breach, including what steps wehave taken in response to the breach and what you may do to reduce the risk of harm from the breach.
EXERCISING YOUR RIGHTS
Making a Written Request.You must submit a written request to exercise your rights under this Notice. Your request should be mailed to Attention: PrivacyOfficer, Autism Spectrum Therapies, 2550 North Hollywood Way, Suite 102, Burbank, CA 91505.If you believe your privacy rights have been violated, you can file a complaint with us by mailing the complaint to Attention: PrivacyOfficer, Autism Spectrum Therapies, 2550 North Hollywood Way, Suite 102, Burbank, CA 91505. You may also file a complaint with theSecretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of yourrights. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact us:
By phone: (888)-550-2666;
By email: firstname.lastname@example.org; or
By mail: Attention: Privacy Officer,
Autism Spectrum Therapies
2550 North Hollywood Way, Suite 102
Burbank, CA 91505.
As a patient, you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by emailor other electronic means.
EFFECTIVE DATE: This Notice of Privacy Practices is effective January 30, 2017
I acknowledge receipt of this Notice of Privacy Practices.
If Client is a Minor, Parent or Guardian Name: