Dyad Mental Health, PLLC
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 IT CAREFULLY.
I respect your privacy. I understand that your personal health information is very sensitive. I will not disclose your information to others unless you tell me to do so, or unless the law authorizes or requires me to do so.
The law protects the privacy of the health information I create and obtain in providing care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows me to use and disclose your protected health information for purposes of treatment and health care operations. State law requires me to get your authorization to disclose this information for payment purposes.
Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations
Under the law, I may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways I may use and disclose your protected health information without your permission. For each category, I will explain what I mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose health information will fall within one of the categories.
Below are examples of uses and disclosures of protected health information for treatment, payment, and health care operations.
- Information obtained by me will be recorded in your medical record and used to help decide what care may be right for you.
- I may also provide information to others providing you care. These other providers include doctors providing substitute services on my behalf, and/or supervisory or consultative services. This will help them stay informed about your care.
- I may request payment from your health insurance plan. Health plans need information from me about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care. I will bill you or the person you designated as responsible for paying for your care if it is not covered by your health insurance plan.
For health care operations:
- I may use your medical records to assess quality and improve services.
- I may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff
- I may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
- I may use and disclose your information to conduct or arrange for services, including:
- medical quality review by your health plan;
- accounting, legal, risk management, and insurance services;
- audit functions, including fraud and abuse detection and compliance programs.
- I may disclose your information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
- These agencies include: government agencies, organizations that provide financial assistance to medical programs (such as third-party payors) and peer review organizations performing utilization and quality control.
- If I disclose PHI to a health oversight agency, to the extent I am required by law I will have an agreement in place that requires the agency to safeguard the privacy of your information.
Your Health Information Rights
The health and billing records I create and store are the property of the practice, Dyad Mental Health, PLLC. The protected health information in it, however, generally belongs to you. You have a right to:
- Receive, read, and ask questions about this Notice;
- Ask me to restrict certain uses and disclosures. You must deliver this request in writing to me. I am not required to grant the request. But I will comply with any reasonable request granted as long as it does not pose a risk to your or others safety.
- Request and receive from me a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”);
- Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing.
- Have me review a denial of access to your health information—except in certain circumstances;
- Ask me to change your health information. You may give me this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.
- When you request, I will give you a list of disclosures of your health information. The list will not include disclosures to third party payors or disclosures that you have requested. You may receive this information without charge once every 12 months. I will notify you of the cost involved if you request this information more than once in 12 months.
- Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.
- Cancel prior authorizations to use or disclose health information by giving me a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before I have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please contact:
Catherine Davies, MD
PO Box 11744
Bainbridge Island, WA 98110
I am required to:
- Keep your protected health information private;
- Give you this Notice;
- Follow the terms of this Notice.
- Notify you if I become aware of a breach of your unsecured protected health information
I have the right to change my practices regarding the protected health information I maintain. If I make changes, I will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting my website at: www.dyadmentalhealth.com
To Ask for Help or Complain
If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:
Catherine Davies, MD at 206-954-3195
If you believe your privacy rights have been violated, you may discuss your concerns with me. You may also deliver a written complaint to Catherine Davies, MD at Dyad Mental Health, PLLC at 727 Ericksen Ave NE, Suite 3, Bainbridge Island, WA 98110. You may also file a complaint with the U.S. Secretary of Health and Human Services Office for Civil Rights.
I respect your right to file a complaint with me or with the U.S. Secretary of Health and Human Services (OCR). If you complain, I will not retaliate against you.
Other Disclosures and Uses of Protected Health Information
Required by Law: I must make any disclosure required by state, federal, or local law
Business Associates: I may contract with individuals and entities to perform jobs for me or to provide certain types of services that may require them to create, maintain, use, and/or disclose your health information. I may disclose your health information to a business associate, but only after they agree in writing to safeguard your health information. Examples include billing services, accountants, IT professionals, pharmacists and others who perform health care operations for me.
Notification of Family and Others
- Unless you object, I may release health information about you to a friend or family member who is involved in your medical care. I may also give information to someone who helps pay for your care. I may tell your family or friends your condition and that you are in a hospital. In general, this will only be done in an emergency. In addition, I may disclose health information about you to assist in disaster relief efforts.
I may use and disclose your protected health information without your authorization as follows:
- With medical researchers—if the research has been approved and has policies to protect the privacy of your health information. I may also share information with medical researchers preparing to conduct a research project.
- To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
- To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
- To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
- To comply with workers’ compensation laws–if you make a workers’ compensation claim. Washington State law requires the disclosure of protected health information to the Department of Labor and Industries, the employer, and the payer (including a self-insured payer) for workers’ compensation and for crime victims’ claims. Disclosure may also be made for work-related conditions that could affect employee health; for example, the assessment of health risks on a job site.
- For Public Health and Safety purposes as allowed or required by law:
- to prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
- to public health or legal authorities
- to protect public health and safety
- to prevent or control disease, injury, or disability
- to report vital statistics such as births or deaths.
- To report suspected Abuse or Neglect to public authorities.
- To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
- For Law Enforcement purposes such as when I receive a subpoena, court order, or other legal process, or you are the victim of a crime.
- For Health and Safety oversight activities. For example, I may share health information with the Department of Health.
- For Disaster Relief Purposes. For example, I may share health information with disaster relief agencies to assist in notification of your condition to family or others.
- For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask me to assess health risks on a job site.
- To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require me to provide information necessary to a military mission.
- In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
- For Specialized Government Functions. For example, I may share information for national security purposes.
Other Uses and Disclosures of Protected Health Information Requiring Patient Authorization
Certain uses and disclosures of your health information require your written authorization. The following list contains the types of uses and disclosures that require your written authorization:
- Psychotherapy Notes: Psychotherapy notes are notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. If I record or maintain psychotherapy notes, I must obtain your authorization to use or disclose your psychotherapy notes with the following exceptions.
- As required by reporting laws (eg, child abuse, dependent adult abuse) and disclosures necessary to prevent harm to you or others
- I may use the notes to carry out your treatment. I may use or disclose your notes for training purposes within the ambit of confidentiality, or to defend a legal action or other proceeding brought by you. I may use the notes to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner or as otherwise required by law.
- Marketing Communications: I must obtain your authorization to use or disclose your health information for marketing purposes other than for face to face communications with you, promotional gifts of nominal value, and communications with you related to currently prescribed drugs, such as refill reminders.
- Sale of Health Information: disclosures that constitute a sale of your health information require your authorization.
In addition, other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization. You have the right to cancel prior authorizations for these uses and disclosures of your health information by giving me a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before I receive the revocation.
Effective Date: This notice is effective as of January 1, 2022