NOTICE OF PRIVACY PRACTICES - HIPAA DATA USE AGREEMENT

MindSpa, LLC is required to abide by the terms of this Notice of Privacy Practices and the laws that protect the privacy and confidentiality of health and care information. My rights regarding my healthcare information are outlined below in this Notice of Privacy Practices form. It also describes my rights to access and control my protected health information. “Protected health information” is information about me, including demographic information, that may identify me and that relates to my past, present, or future physical or mental health or condition and related health care services.

In summary, Information obtained during visits that identify me will not be given to anyone without my consent except for the purposes of treatment, payment, healthcare operations, and for other purposes that are permitted or required by law. My protected health information may be used and disclosed by my physician, office staff, and others outside of the office who are involved in my care and treatment for the purpose of providing health care services to me. My protected health information may also be used and disclosed to pay my health care bills and to support the operation of my physician’s practice.

Following are examples of the types of uses and disclosures of my protected health information that my physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by the office.

DISCLOSURES: MindSpa, LLC may disclose my information for the following reasons:

• Treatment: To provide services and care, my information will need to be disclosed to the treatment team, office staff, and my provider. Additionally, MindSpa, LLC may consult other providers to discuss my care, such as collaborating physicians or my pharmacist.
• Health Care Operations: Internal staff and third-party business associates may require my information to conduct essential tasks such as scheduling, licensing, training, teaching medical students, employee reviews, quality improvement, and other business functions. MindSpa, LLC and all third parties have a written contract to protect my health information.
• Bill for Services: Internal or third-party billers or entities, as well as insurance companies, may need to review my healthcare information to determine eligibility, approve services, determine medical necessity, and conduct utilization management before paying for my treatment.
• MindSpa, LLC May Disclose My Information if subpoenaed, to public health authorities, the FDA, health oversight agencies, detention centers, coroners, funeral directors, organ donators, workers’ compensation programs, and Military Activity and National Security, in certain circumstances. They may be required to report certain communicable diseases, elder or child abuse or neglect, and criminal activity. Law enforcement may be notified if I am at risk of harming myself or someone else. MindSpa, LLC may disclose certain information for research, if approved by an institutional review board.
• Other Uses and Disclosures of My Healthcare Information Require My Written Authorization. I may revoke written authorization at any time. If I revoke my authorization, MindSpa, LLC will no longer use or disclose my protected health information for the reasons covered by my written authorization. I understand that MindSpa, LLC is unable to take back any disclosures already made with my authorization.
• Other Permitted and Required Uses and Disclosures That Require Providing me the Opportunity to Agree or Object: Unless I object, MindSpa, LLC may disclose to my emergency contact or to a member of a relative or a close friend, or another person I identify, my protected health information that directly relates to that person’s involvement in my health care. If I am unable to agree or object to such a disclosure, MindSpa, LLC may disclose such information as necessary if they determine that it is in my best interest based on their professional judgment. They may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for my care of my location, general condition, or death. Finally, they may use or disclose my protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in my health care.

MY RIGHTS:

1. Get an electronic copy or a paper copy of my medical record. If requested, MindSpa, LLC will provide me a summary of my health information, usually within 30 days of my request. There may be a small fee to do so.
2. Request a change in my medical record. If I believe something in my record is incorrect, I can request a change. If MindSpa, LLC says “no,” they will provide me with written reasoning within 60 days.
3. Request confidential communications. I may ask MindSpa, LLC to contact me in a specific way or use a specific means of communication (for example, only my personal phone). MindSpa, LLC will adhere to all reasonable requests.
4. Right to request a restriction. I may want to limit certain aspects of my health information such as treatment, payment, or operations, however, MindSpa, LLC may say “no” if it affects my care, safety, or if the law requires the information. Additionally, I can request that any part of my health information not be disclosed to any family member or friend not directly involved in care.
5. Get a list of those with whom we’ve shared information. MindSpa, LLC can provide me a list of disclosures, if any. This list will not include disclosers to those involved in treatment, payment, or healthcare operations, or those in whom I consented or asked MindSpa, LLC to make. MindSpa, LLC will provide one accounting a year for free but will charge a fee for a second within the same 12 months.
6. Get a copy of this privacy notice. I can ask for a copy of this notice at any time. I can also find this form in my patient portal and on MindSpa, LLC’s website.
7. Choose someone to act for me. If I have given someone medical power of attorney or if I have a legal guardian, that person may exercise my rights and make choices about my healthcare information.
8. File a complaint if I feel my rights have been violated. I can make complaints to MindSpa, LLC or to the U.S. Department of Health and Human Services by visiting www.hhs.gov/ocr/privacy/hippa/complaints without fear of retaliation.

MindSpa, LLC may change the terms of their notice, at any time. The new notice will be effective for all protected health information that they maintain at that time. Upon my request, they will provide me with any revised Notice of Privacy Practices. I may request a revised version by accessing their website or calling the office and requesting that a revised copy be sent to me in the mail or asking for one at the time of my next appointment.

By signing this form, I understand all the above and consent to the following:

1. I have received and fully read the Notice of Privacy Practices and I understand my rights as a patient.
2. MindSpa, LLC may use and disclose my protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law.
3. I understand that information obtained within the context of treatment is confidential and can ordinarily be released only with my written permission unless for certain situations, as mentioned above.
4. I will sign a Release of Medical Information consent prior to my information being released for care coordination for reasons other than those noted in this HIPPA Data Use Agreement, which can be revoked at any time. However, I understand MindSpa, LLC is unable to take back anything that has already been disclosed.
5. I understand that by signing this form, unless otherwise written in writing, I give MindSpa, LLC consent to contact and release personal healthcare information to my emergency contact that I listed on my intake form in the event of an emergency or psychiatric crisis. I have the right to change my emergency contact at any time.
6. I understand that by signing this form, unless otherwise written in writing, I give permission for MindSpa, LLC to call, text, or email general information about my appointments or educational references. I understand the right to request a change in these communications and revoke this consent at any time.
7. I understand that safety concerns may require the presence or involvement of additional personnel, in which my permission may not be required.
8. I further understand that there are circumstances that can limit confidentiality including but not limited to:  A statement of harm to myself or others, criminal activity, and/or issuance of a subpoena from a court of law.