CLIENT RIGHTS AND NOTICE OF PRIVACY PRACTICES:
You and your therapist will together develop a plan for treatment which addresses your needs. You have the right to read and give written approval of the Treatment Plan.
If you are dissatisfied with the services you are receiving, discuss this with your therapist. If after careful consideration of the issue over time you and the therapist cannot come to an understanding, the next step would be to take the problem to David Dougher, Director of Outpatient Services. If at that point you feel that you have received services that are not appropriate or are discriminatory, you can request a formal hearing process (details available upon request).
September 1, 2016
NOTICE OF PRIVACY PRACTICES
We are required by law to give you this notice. It will tell you the ways in which we may use and disclose health information about you and describes your rights and our obligation regarding the use and disclosure of that information.
If you have any questions about this notice, please contact Molly Dinsdale of our office at (503) 588-2004 at 965 Liberty St. SE, Salem, OR 97302-4138
Right to Request Restrictions:
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.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION to your therapist.
WE MAY USE AND DISCLOSE HEALTH INFORMATION FOR THE FOLLOWING PURPOSES:
For treatment: As part of treatment, 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
For payment: Insurance companies have the right to know for billing and payment purposes.
For Health Care Operations: To set up a file, attend to appointment issues, provide billing
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. We are required by law to report suspected child abuse, injury or neglect of a person 65 years of age or older and abuse of a mentally disabled adult to appropriate authorities.
Public Health Risks. We may disclose information about you for public health reasons in order 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 health care system, government programs and
compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose health
information about you in response to a court or administrative 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
applicable legal requirements.
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.
We will not disclose your health information unless there is written authorization by you. If there is a medical emergency, we may, using our professional judgment, determine that a limited disclosure to a family member or friend is in your best interest.
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 copy your health information such
as clinical and billing records that we keep and use to make decisions about your care. You must
submit a written request to your therapist in order to inspect and/or copy records of your health
information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies.
We may deny your request to inspect and/or copy in certain limited circumstances. If you are
denied copies of or access to health information that we keep about you, you may ask that our
denial be reviewed. If the law gives you a right to have our denial reviewed we will select a
licensed health care professional to review your request and our denial. The person conducting the
review will not be the person who denied your request, and we will comply with the outcome of
Right to Amend. If you believe health information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request an amendment as long as
the information is kept by this office.
To request an amendment, complete and submit a CLINICAL RECORD
AMENDMENT/CORRECTION FORM to your therapist.
We may deny your request for an amendment if your request is not in writing or does not include
a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
We did not create, unless the person or entity that created the information is no longer
available to make the amendment.
Is not part of the health information we keep
You would not be permitted to inspect and copy
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of
Disclosures.” This is a list of the disclosures we made of clinical information about you for
purposes other than treatment, payment, health care operations or based on your authorization.
Right to Request Restrictions. You have the right to request a restriction or limitation on health
information we use or disclose about you for treatment, payment or health care operations.
We are not required to agree to your request. If we do agree, we will comply with your request
unless the information is needed to provide you emergency treatment.
Right to Request Restrictions. To request restrictions you may complete and submit the
REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF CLINICAL INFORMATION to
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office contact Molly Dinsdale, Co-Director, (503) 588-2004, 965 Liberty St. SE, Salem, OR 97302-4138.
Thank you, Poyama Staff