HIPAA “Notice of Privacy” Practices Statement for
Montessori Autism Programs & Services, Inc.
1106 Windfield Way
916-357-5837
Effective February 5, 2013
This notice describes how medical information about you (“Protected Health Information”-PHI) that is in Montessori Autism Programs & Services, Inc. (M.A.P.S.) possession, according to the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client/patient rights regarding use and disclosure of your PHI. Please read it carefully.
Who Will Follow This Notice
This notice describes the medical/healthcare information privacy practices of M.A.P.S. and that of any third party that assists in the administration of insurance carrier claims.
Our Pledge Regarding Medical/Healthcare Information
We understand that the information about you and your health is personal. M.A.P.S. understands that keeping your health care information private is one of our most important responsibilities. We are committed to protecting your health care information and following all laws about its use. This notice applies to all the health care information we maintain. M.A.P.S. is required by law to:
- Ensure that health care information that identifies you is kept private;
- Give you this notice of our legal duties and privacy practices with respect to medical/healthcare information about you; and
- Follow the terms of the notice.
How We Collect Information About You
M.A.P.S. and its employees collect data through a variety of means including but not limited to letters, phone calls, emails, voice mails, and from the submissions of authorization that is either required by law, or necessary to process services or other requests for assistance through our organization.
How We May Use and Disclose Health Information About You
The following categories describe different ways that we use and disclose medical information. Information is only used as is reasonably necessary to process your approval to receive services or to provide you with services which may require communication between M.A.P.S. and health care providers, service providers, insurance companies, and other providers necessary to: verify your medical information is accurate and to determine the type of services you need.
Treatment, Payment, and Organizational Operations:
We may use or disclose your PHI to obtain payment for services we provide to you or to determine eligibility or coverage for services. We review your healthcare information and submit claims to payers you have agreements with to make sure that you get quality care and that all laws about providing and paying for your health care are being followed. We may also use your PHI in connection with clinical quality measures and in order to operate our office in an efficient and quality manner. This may include quality assessment and evaluation, licensure/credentialing activities, providing appointment reminders, training, audits, administrative/office services, case management/case coordination, among similar activities.
Professional Records
You should be aware that, pursuant to HIPAA, we keep clients’ Protected Health Information in three (3) sets of professional records. One set constitutes the Clinical Records, the second set is the Personal Notes, and the third are the Billing Records.
(1) The Clinical Record includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment; consultative; or therapeutic goals; progress towards those goals; a medical, developmental, educational and social history; treatment history; any treatment records that we receive from the providers; releases; reports of an professional consultations; formal clinic notes of treatment and treatment data; and any clinical or evaluation reports that have been sent to anyone, including your insurance carrier. The client or his/her authorized legal representative may examine and/or receive a copy of the Clinical Record, if requested in writing. In most situations, we are allowed to charge a fee for copying (and for certain other expenses) plus postage.
(2) Personal Notes are taken by our professionals for clients that we provide direct ABA treatment to. While the content of the Personal Notes vary from client to client, most are anecdotal notes related to progress and future goals, reference to conversations, and hypotheses of the professional in order to assist him/her to provide you with the best treatment. These notes are kept separate from the Clinical Record as they are for the use of the professional alone, and are not available to the client or his/her authorized representative, or anyone else, including third party payers. Your signature below waives all rights, now and in the future, to accessing these records in any form under any circumstance. Insurance companies or other funding sources cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.
(3) Billing Records are kept separate from the Clinical Record and Personal Notes. The Billing Record for each client can vary based on individual circumstances, but can include authorization for services, invoices, and verification of services, releases, billing statements, credit card authorizations, financial agreements/contracts, and related confidential financial records. The client or his/her authorized legal representative may examine and/or receive a copy of the Billing Record, if requested in writing. In most situations, we are allowed to charge a fee for copying (and for certain other expenses) plus postage.
Uses Pursuant to an Authorization:
As permitted by federal and state law, we may disclose our PHI with your consent. You may generally revoke your consent in writing at any time to the extent we have not already relied on that consent. In other words, we cannot take back any uses or disclosures already made with your permission. It is understood that such consent may authorize the release of information to which you have not had access or to information that has not been generated at the time of the execution of the release.
Further Disclosures:
We follow federal and state laws that tell us when we are required to share health care information, even if you do not sign an authorization form. Federal and state laws do not require patient/client consent for the following disclosures:
- Abuse or Neglect: We must report information that leads us to reasonably suspect child abuse or neglect, or that an elderly or disabled adult is in need of protective services. We must also comply with a request from state and federal agencies to release records relating to abuse or neglect investigations.
- Judicial/Administrative Proceedings: We must comply with an appropriately issued court order or subpoena that requires that we release your PHI.
- Serious Threat to Health or Safety: We may be required to disclose your PHI to protect you or others from a serious threat of harm, including, but not limited to: contagious diseases; firearm injuries and other trauma; and reactions to problems with medications or defective medical equipment; to the police when required by law.
- Others We May Be Required to Share Your Information With: We may be required to disclose your personal health information: to the government to review how our programs are working; to an insurance company who needs to know if you received services from us; to Worker’s Compensation for work related injuries; to the government during the course of an investigation or for serious threats to public health or safety.
Patient/Client Rights
- You have a right to request restrictions on certain uses and disclosures of PHI; however, federal law does not require that we comply with all requests. You can request and receive confidential communications of PHI by specified means/alternative locations.
- You may inspect or obtain a copy of PHI in certain circumstances when requested in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. M.A.P.S. may deny your request to inspect and copy in certain, very limited, circumstances; if denied access, you may request that the denial be reviewed.
- If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information in writing, so long as we maintain that information in our records. Federal law does not require us to agree to each such request (for example, when the information was not created by us). We will answer your questions about the amendment process.
- You have a right to receive an accounting of most disclosures of PHI, where such disclosure was made for any purpose other than treatment, payment, or M.A.P.S. operations, for which you have not provided consent. Requests must be made in writing, state a time period not longer than six years, and may not include dates before ____________. Your request should indicate what form you want (paper or electronic). The first list you request within a 12-month period will be free. For additional lists, we will charge you for the costs of providing the list. We will notify you of the cost involved and ask for your consent.
- You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member. We are not required to agree to your request. To request restrictions, you must make your request in writing. In your request, you must tell us: what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.
- You have the right to request that we communicate with you about medical maters in a certain way or a certain location. To request confidential communications, you must make your
request in writing. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- You have a right to obtain a paper copy of this notice for us upon request.
Changes to This Notice
M.A.P.S. reserves the right to change this notice. We reserve the right to make revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will send you a copy of any changed notice in the U.S. mail within 30 days. Revised notices will contain the effective date.
Complaints
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. You will not be penalized for filing a complaint.