Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $2.00 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.
Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.
Be Well is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If Be Well revises policies and procedures, we will provide you with a revised notice in office during the next session.
For Treatment –Your therapist will use and disclose your health information internally in the course of your treatment. If you wish to provide information outside of Be Well for your treatment by another health care provider, your therapist will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
For Payment – your therapist may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
For Operations – your therapist may use and disclose your health information as part of Be Well's internal operations. For example, this could mean a review of records to assure quality. Your therapist may also use your information to tell you about services, educational activities, and programs that they feel might be of interest to you.
The law protects the privacy of all communication between a patient and a therapist. In most situations, your therapist can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where your therapist is permitted or required to disclose information without either your consent or authorization. If such a situation arises, your therapist will limit disclosure to what is necessary. Reasons your therapist may have to release your information without authorization:
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. Your therapist cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if your therapist receives a subpoena of which you have been properly notified and you have failed to inform your therapist that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order your therapist to disclose information.
If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, your therapist may be required to provide it for them.
If a patient files a complaint or lawsuit against an individual therapist, your therapist may disclose relevant information regarding that patient in order to defend themself.
If a patient files a worker’s compensation claim, and your therapist is providing necessary treatment related to that claim, your therapist must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.
Your therapist may disclose the minimum necessary health information to business associates that perform functions on Be Well's behalf or provide us with services if the information is necessary for such functions or services. Be Well associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other 1. Health Insurance Portability Accountability Act (HIPAA) than as specified in our contract.
There are some situations in which your therapist is legally obligated to take actions, which they believe are necessary to attempt to protect others from harm, and may have to reveal some information about a patient’s treatment:
If your therapist knows, or has reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that your therapist file a report with the local Child Protection Agency. Once such a report is filed, your therapist may be required to provide additional information.
If your therapist knows or has reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that your therapist file a report with the local Adult Protection Agency. Once such a report is filed, your therapist may be required to provide additional information.
If your therapist believes that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, your therapist may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
(OMB Control Number: 0938-1401)
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
If you choose to use your out of network benefits, you will receive a Good Faith Estimate for the cost of service.
If you believe you’ve been wrongly billed, you may contact: www.cms.gov/nosurprises/consumers
For more information about your rights under this Federal Law please visit: https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf