HIPAA Notice of Privacy Practices for Protected Health Information

We have a duty to protect the confidentiality of information about you. We are required to provide you with a Notice of Privacy Practices explaining the ways we may use and disclose your information.
The Notice of Privacy Practices will be followed by any employee affiliated with Synergy Counseling Services, LLC.

Your Rights
You have the right to:

• Get a copy of your paper or electronic medical record (Psychotherapy notes are afforded special privacy under HIPAA regulations and are excluded from this right)
  • Ask us how to request a copy of your medical record. We will provide a copy or summary of your health information. Usually within 30 days of your request. We may charge a reasonable, cost- based fee.
• Correct your paper or electronic medical record (Psychotherapy notes are afforded special privacy under HIPAA regulations and are excluded from this right)
  • You can ask us to correct health information about you that you think is incorrect or incomplete. We may so “no” to your request, be we’ll tell you why in writing within 60 days.
• Request confidential communication
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
• Ask us to limit the information we share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • 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 insurance. We will say “yes” unless a law requires us to share that information.
• Get a list of those with whom we’ve shared your information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
• File a complaint if you believe your privacy rights have been violated
  • You can complain if you feel we have violated your rights by contacting us using the information on the last page of this form.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence
    Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Your Choices
You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Providing disaster relief
  
• Provide mental health care
  • If you are not able to tell us your preference, for example if you are
    unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed
    to lessen a serious and imminent threat to health or safety.
• Market our services and sell your information – in these cases we never share your information unless you give us written permission:
• Raise funds – We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
We may use and share your information as we:

• Treat you – We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Run our organization – We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
• Bill for your services- We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
• Help with public health and safety issues – We can share health information about you for certain situations such as: Preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence
• Comply with the law – We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests – We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director – We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests – For workers’ compensation claims, For law enforcement purposes or with a law enforcement official, With health oversight agencies for activities authorized by law, For special government functions such as military, national security, and presidential protective services.
• Respond to lawsuits and legal actions – We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Use/disclosure of the following health information does not require your consent or authorization:

• Public Health Activities (WHO, STD’s)
• Victims of abuse, neglect, domestic violence (like duties to warn)
• Health oversight activities (correcting records)
• Judicial/Administrative proceedings (like files subpoenaed)
• Law Enforcement Purposes (like when a client claims mental health issues as a defense)
• Research Purposes – We can use or share your information for health research.
• Serious threats to health/safety that may be averted by disclosure
• Psychotherapy notes

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice

• We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

• Our practice requires any request regarding your healthcare records in writing.
• We never market or sell personal information.
• As a client, you have the right to restrict use and disclosure of your PHI for the purpose of treatment, payment, and operations. If you choose to release any PHI, you will be required to sign a Release of Information form detailing exactly to whom and what information you wish to disclose. Our office will not release information from our clients signing another entity release of information. The signed release must be our internal form.
• For more information regarding our privacy notice please contact Synergy Counseling Services privacy official at, referral@scs-helps.com, scs-helps.com or contact us at 1-800-552-4357. The new notice will be available upon request, in our office, and on our website. You may also request a copy by writing to us at: 627 Trolley Road Suite A Summerville, SC 29485-5673