Notice Of Privacy Practices
This document contains important information about Healthcare Portability and Accountability Act (HIPAA), a federal law that regulates the use, privacy protection, and disclosure of your PHI (protected health information).
This notice outlines our legal duties and practices, your rights and how to avail those rights.
The PHI (protected health information) may include information about your past, present, or future physical or mental health condition, payment for care, PHI can be maintained or transmitted in any form or medium.
Effective date of this Notice:
This goes into effect 11/16/21.
Confidentiality Of Your PHI.
We maintain confidentiality of your PHI, by following the Federal, and Ohio guidelines, except as described in this notice. It is our practice to obtain prior authorization before we disclose any information to any person or party.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
Under the Health Insurance Portability and Accountability Act of 1996 (hereafter, “HIPAA”), you have certain rights regarding the use and disclosure of your protected health information (hereafter, “PHI”).
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record 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 I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.
I am required by law Make sure that PHI that identifies you is kept private. Give you this notice of my legal duties and privacy practices with respect to health information Following the terms of the notice that is currently in effect I can change the terms of this Notice, and such changes will apply to all the information I have about you. The new Notice will be available upon request, in my office, and on my website.
The Use and Disclosure of Your PHI Permitted by HIPPA:
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
For Treatment Purposes: It is necessary to use your PHI for providing service, treatment, coordination and management of service by one or more healthcare providers. This may include consultation for treatment from other health care providers, or referrals for other providers.
For Payment Purposes: We may use your information to obtain payment, confirm eligibility for services, billings, claims, collections.
Continued Healthcare Operations: We may use your information within the company to carry out the health care related operations, for business management, retrieval of healthcare information, administrative duties, quality assessment and improvement of services. We may also use the information for Medical, legal and accounting reviews, business planning and development and licensing and training.
Appointments and Services Rendered: We may need to use your information to schedule appointments, treatment alternatives or other related benefits that may be useful to you.
Family Members and Others Involved in your Healthcare:
Subject to the decision to agree or to object, we may share your information with the family members thus identified by you as your (personal representative), such as a personal friend, spouse, relative, this information will be directly relevant to the personal representative’s involvement in your care for payment or services. An example may be your parent and or a caregiver to a minor.
Uses of your PHI Requiring Authorization: We may disclose your information to another party or health care entity based on your release and authorization. The release of information is your authorization in written form to allow us to disclose your information to a relevant party based on the extent or limitations described by you for the information. In those instances, a prior authorization form will be obtained before such a disclosure is made on your behalf.
Exceptions to Disclosure of your PHI Not Requiring Prior Consent or Authorization:
Exceptions to maintain privacy may occur under strictly limited situations, under which, we may disclose your PHI without prior consent and release or authorization.
The circumstances are in the instances of:
To report neglect or abuse
To avert serious threat to the health and safety of self or others (person or public)
In response to subpoenas and other requests to provide information for courts or administrative proceedings.
In response to workers compensation claims
Emergency situations based on professional judgment.
Clients Rights Regarding PHI.
Right to Request restriction:
You have the right to request a limitation/ restriction on the disclosure of your PHI. You may choose to limit the PHI we disclose on your behalf to your family members, friends, or personal representative. However, we are not required to agree to this restriction, we will not use/ disclose that information pursuant to that restriction. You may request a restriction by giving us a notice in writing, to include, a) what PHI you would like excluded, b) whether you want to limit use or disclosure or both, c) The identified person or entities that you want us to restrict access thereof.
Right to request confidential communication:
You have a right as a client to request confidential communication, you can communicate your preferences for the mode of communication, limited to or to include texts, email or phone call. You can also specify if you want us to contact your cell or home phone.
Right to Inspect or copy:
You have a right to inspect or copy your PHI contained in your health records,
With the exception of psychotherapy notes, information compiled in an expectation of a civil, criminal, administrative action or an ongoing proceeding.
You may be denied access if your PHI contains information pertaining to another person’s confidential disclosure likely to endanger the life or physical safety of another person. A decision to deny access may be reviewed. If records are requested a fee may be charged for preparation and retrieval.
Right to Amend:
If you believe that there is information contained in your records that is not accurate, you have rights pertaining to that. You can submit a written request detailing what information on our record is inaccurate and needs amendment. Additionally, we may choose to deny amendments to diagnosis and treatment rendered prior to your treatment at this private practice. Amendments may also be denied if they do not include any supporting documentation. We may also not be able to make amendments to existing records if the provider/person is no longer a part of this private practice.
Rights to Receive an Accounting of Disclosures:
You have a right to receive the list of disclosures made on your behalf. This is a list of disclosures made by the private practice on your behalf. We are not required to provide a list of disclosures for billing, administrative actions, treatment, payment, or other authorized operations that may be a part of the authorizations already on file with you.
Rights to a Paper Copy of this Notice:
You have a right to receive a paper copy of this notice upon your request.
Complaints: If you are concerned that we have violated your privacy rights, or you are in disagreement that was made in regards to access of your records,
Please contact the office at 440-201-4258.
Client obligations:
Co-pays:
Co-pays and payments are required to be paid at the time when services are rendered, we prefer a credit card.
Insurances accepted:
Medicaid /Cash Pay out of Network rates:
Are as follows:
Intake Assessment appointment 90791= $120
Follow up session 90834 (45 min) sessions $85
Follow up session 90837 (53 mins or more) =$109
Intake assessments are performed once a year.
Follow up session 90832 (16-30 mins) $60
Treatment planning every 3 months no additional cost.
Yearly cost estimates 50 weeks in a year 50 sessions $85= $4250
Biweekly 25 sessions x $85= $2125
Yearly cost for 50 weekly for 53 mins sessions $109×50= $5450
Biweekly cost $109×25=$2725
We offer sliding scale.
Forms of payment:
All major credit cards are accepted.
No show/ cancellations Policies:
The cancellation policy requires a $50 fee for cancellations that are made prior to 48 hours.
Credit card information on File:
We may store your credit card information on file within our EHR system, for your convenience we store that information on autopay for recurrent payments for services. Please let us know, if you do not wish to be included in autopay. Please let us know if you need to update any information on file. For discrepancies with billing please contact, hina@thehealinglighttherapy.com Or call us at 440-201-4258