Aspergers & Autism
A set of complex brain-based differences that can impact a person’s communication, sensory processing, social interactions, intimate relationships, and behavior. The CDC estimates that 2.2% of adults in the USA are on the spectrum of autism.
Form 3: HIPAA NOTICE OF PRIVACY PRACTICES
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Understanding Your Protected Health Information (PHI) When you visit us, a record is made of your symptoms, examinations, test results, diagnoses, treatment plan, and other mental health or medical information. Your record is the physical property of the medical health care provider. The information within belongs to you. Being aware of what is in your record will help you to make more informed decisions when authorizing disclosures to others. In using and disclosing your PHI, it is our objective to follow the Privacy Standards of the Federal Health Insurance Portability and Accountability Act (HIPAA) and requirement of state law.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
Your Mental Health and/or Medical Record Serves as:
A basis for planning your care and treatment.
A means of communication among the health professionals who may contribute to your care.
A legal document describing the care you received.
A means by which you or a third-party payer can verify that services billed were actually provided.
A source of information for public health officials charged with improving the health of the nation.
A source of data for facility planning and marketing.
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
Responsibilities of Spectrum Services. We are required to:
Maintain the privacy of your PHI as required by law and provide you with notice of legal duties and privacy practices with respect to the PHI that we collect and maintain about you.
Abide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and to make the new provisions effective for all protected health information that we maintain, including that obtained prior to the change. Should our information practices change, we will post new changes in the reception room and provide you with a copy.
Notify you if we are unable to agree to a requested restriction.
Use or disclose your health information only with your authorization except as described in this notice.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
Your Protected Health Information (PHI) Rights. You have the right to:We are required to:
Review and obtain a paper copy of the notice of information practices and your health information upon request. A few exceptions apply. Copy charges may apply.
Request and provide written authorization and permission to release PHI for purposes of outside treatment and health care. This authorization excludes psychotherapy notes and any audio/video tapes that may have been made with your permission for training purposes.
Revoke your authorization in writing at any time to use, disclose, or restrict health information except to the extent that action has already been taken.
Request a restriction on certain uses and disclosures of PHI, but we are not required to agree to the restriction request. You should address your restriction in writing to the Privacy Officer by asking for name of the Privacy Officer, address, and phone. We will notify you within 10 days if we cannot agree to the restriction.
Request that we amend your health information by submitting a written request with reasons supporting the request to the Privacy Officer. We are not required to agree with the requested amendment.
Obtain an accounting of disclosures of your health information for purposes other than treatment, payment, health care operations, and certain other activities for the past six years but not before April 14, 2003.
Request confidential communications of your health information by alternative means or at alternative locations.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
Disclosures for Treatment, Payment, and Health Operations. Spectrum Services will use your PHI, with your consent, in the following circumstances:
Treatment: Information obtained by a nurse, physician, psychologist/counselor, dentist, or another member of your health care team will be recorded in your record and used to determine the management and coordination of treatment that will be provided for you.
Disclosure to others outside of the agency: If you give us written authorization, you may revoke it in writing at any time but that revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your health information without your authorization, except to report a serious threat to the health or safety of a child and/or vulnerable adult.
For payment, if applicable: We may send a bill to you or to your insurance carrier. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis to obtain reimbursement for your health care or to determine eligibility or coverage.
For health care operations: Members of the mental health staff or members of the quality improvement team may use the information in your health record to assess the performance and operations of our services. This information will be used in an effort to continually improve the quality and effectiveness of the mental health care and services we provide.
We may use or disclose your PHI in the following situations without your authorization: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse/neglect, Food and Drug Administration requirements, legal proceedings, law enforcement, coroners and organ donation, research, or workers’ compensation. Under the law, we must make disclosures to you when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
For More Information or to Report a Problem If you have questions and would like additional information, please ask your clinician. He/she will provide you with additional information or put you in contact with the designated Privacy Officer. If you are concerned that your privacy rights have been violated or you disagree with a decision we have made about access to your health information, you may contact the Privacy Officer. We respect your right to privacy of your health information. There will be no retaliation in any way for filing a complaint with the Privacy Officer of our agency or the U.S. Department of Health and Human Services.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
HIPAA Privacy Authorization for Use and Disclosure of Personal Health Information This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations as amended from time to time. You may refuse to sign this authorization. By my signature below, I acknowledge that I have received and read the Notice of Health Information Privacy Practices. I have been provided a copy of, read, and understand Spectrum Services. HIPAA Privacy Notice containing a complete description of my rights, and the permitted uses and disclosures of my protected health information under HIPAA. Further, I acknowledge that any information used or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and is no longer protected under HIPAA.
Clinical diagnoses or psychological/neurological evaluations
Neurodiverse specialized individual, couple, and family therapy
Trauma work with individuals, couples, and families
Executive functioning and social skills coaching and behavioral interventions
Free support groups in partnership with AANE for family members and adults with AS and related conditions
Groups
