I. PLEDGE REGARDING HEALTH INFORMATION (Privacy Act):

Amy B. Faust, LPC (henceforth referred to as "practitioner") understands that health information about you and your health care is personal. This practitioner is committed to protecting health information about you. A record of the care and services you receive from Amy B. Faust, LPC is maintained in a secured electronic environment. This record is required in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which your protected health information may be used and disclosed about you. Additionally, your rights to the health information kept about you will be described here, and certain obligations regarding the use and disclosure of your health information is described here as well. 

Amy B. Faust, LPC is required by law to:

- Make sure that protected health information ("PHI") that identifies you is kept private.

- Give you this notice of the practitioners duties and privacy practices with respect to health information.

- Follow the terms of the notice that is currently in effect.

- Amy B. Faust, LPC can change the terms of this Notice, and such changes will apply to all information recorded about you. The new Notice will be available upon request.

II. HOW AMY B. FAUST, LPC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that this practitioner may use and disclose health information. For each category of uses or disclosures you will receive an explanation regarding what is meant along with pertinent and examples. Not every use or disclosure in a category will be listed. However, all of the ways in which this provider is permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client's personal health information without the client's written authorization, to carry out the health care provider's own treatment, payment or health care operations. This practitioner may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, your practitioner may disclose health information in response to a court or administrative order. She may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. Amy B. Faust, LPC does keep "psychotherapy notes" as that term is defined in 45 CFR 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For use in treating you.

b. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For use in defending herself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, your PHI will not be used or disclosed for marketing purposes.

3. Sale of PHI. As a psychotherapist, your PHI will not be sold in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, the use and disclosure or your PHI without your Authorization can be done for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although this practitioner's preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on business premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although again, this practitioners preference is to obtain an Authorization from you, she may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. This practitioner may use and disclose your PHI to contact you to remind you that you have a scheduled appointment. She may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that are offered.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. Amy B. Faust, LPC may provide your PHI to a family 

member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. This person is typically listed in your emergency contact record.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask this practitioner not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Amy B. Faust, LPC is not required to agree to your request, and may say "no" if she   believes it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How Your PHI is Sent to You. You have the right to ask this practitioner to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and she will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that this practitioner has about you. You will be provided with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request.  Please be advised that you may be charged a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures This Practitioner Has Made. You have the right to request a list of instances in which Amy B. Faust, LPC has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided with an Authorization. She will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list given you will include disclosures made in the last six years unless you request a shorter time. Amy B. Faust, LPC will provide the list to you at no charge, but if you make more than one request in the same year, you may be charged a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that the existing information be corrected or that the missing information will be added. Should this practitioner refuse your request, you will receive an explanation in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

STANDARD NOTICE

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes  related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose  for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call Amy B. Faust, LPC at (480) 935-6626.