MIND POTENTIAL NORTHWEST, LLC NOTICE OF PRIVACY PRACTICES
The Health Insurance Portability and Accountability Act (HIPAA) –Revised: November 7, 2022
(This notice describes how health information about you may be used and disclosed and how you can get access to this information).
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the health care services you receive at this office. Your health information may include information created and received by this office, which may be in the form of spoken words, written or electronic records, and may include information about your health history, health status, symptoms, examination, test results, diagnoses, treatment, procedures, prescriptions, related billing activity and similar types of health-related information. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose health information for the following purposes:
For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.
For Payment: We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about a service that you received here so your health plan will pay us or reimburse you for the service. We may also tell your plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment.
For Healthcare Operations: We may use and disclose health information about you in order to run the office and make sure that you and our patients receive quality care.
For example: We may disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
Appointment Reminders: We may contact you as a reminder that you have an appointment for treatment or medical care at the office. Please notify us in writing if you do not wish to be contacted for appointment reminders.
Treatment Alternatives: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Products and Services: We may tell you about health-related products or services that may be of interest to you. Please notify us in writing if you do not wish to receive communications about treatment alternatives or health-related products or services.
SPECIAL SITUATIONS
We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law: We will disclose health information about you when required to do so by federal, state, or local law.
Research: We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher has access to your name, address, or other information that reveals who you are, or will be involved in your care at the office.
Military, Veterans, National Security and Intelligence: If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefit for work-related injuries or illness.
Public Health Risks: We may disclose health information about you for public health reasons to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities: We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the healthcare system, government programs, and compliance with civil right laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administration order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement: We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all application legal requirements.
Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner or medical examiner.
Information Not Personally Identifiable: We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends: We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf, (ex-to have someone pick up medical supplies for you).
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission. In some instances, we may need specific, written authorization from you in order to disclose certain types of specialty-protected information such as HIV, substance abuse, mental health, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to inspect and copy: You have the right to inspect and request a copy of your health information, such as medical and billing records. You must submit a written request to Mind Potential Northwest LLC: Attn: HIPAA Privacy Officer. If you request a copy of the information, we may charge a fee for related costs. In certain limited circumstances, we may deny your request to inspect and/or copy records. If you wish to contest the denial and the law gives you a right to have the denial reviewed, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied the request and we will comply with the outcome of the review.
Right to Amend: If you believe that the health information we have on file is incorrect or incomplete, you may ask us to amend the information. Your request must be made in writing and must explain why the information should be amended. If we did not create the information, you want amended or for certain other circumstances, we may deny your request. If we deny your request, we will provide a written explanation. If denied, you have the right to file a statement of disagreement with the decision which we will keep on file.
Right to Accounting of Disclosures: You have the right to request a copy of the list of disclosures we made of medication information about you for the purpose of your treatment, payment, health care operations, and a limited number of special circumstances involving national security correctional institutions and law enforcement. The list will also exclude any disclosures we have made based on your written authorization. Requests must be received in writing and must include a time period which may not be longer than 6 years and may not include dates before April 14, 2003. We may charge a fee for related costs.
Right to Request Restriction: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. We will comply with your requests unless the information is needed to provide you with emergency treatment, or we are required by law to use or disclose the information. All requests for restrictions must be received in writing.
Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at certain locations. For example, you can ask that we only contact you at work or by mail. All requests must be received in writing, and you must specify how or where you wish to be contacted.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. You are entitled to a copy of the notice currently in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office and the Secretary of the Department of Health and Human Services. All complaints must be received in writing and will be reviewed and responded to as appropriate. You will not be penalized for filing a complaint.
The Mind Potential, LLC Compliance and Privacy Officer
Name: Darla Meulemans, MA Address: PO Box 68056, Portland, OR 97268
Phone: 503.757.9557
