Effective date: [insert date] · This notice describes how medical and mental health information about you may be used and disclosed, and how you can access this information. Please review it carefully.
Freedom From Harm ("we," "us," "our practice") is required by law to maintain the privacy of your protected health information (PHI), provide you with this notice describing our legal duties and privacy practices, and follow the terms currently in effect. We are also required to notify you in the event of a breach of your unsecured PHI.
We may use and disclose your health information to provide, coordinate, or manage your treatment and related services — for example, consulting with another treating provider about your care, with your knowledge.
We may use and disclose your health information to bill and collect payment for services, including providing information to your insurance carrier or issuing a superbill for out-of-network reimbursement, where applicable.
We may use your health information for activities such as quality assessment, licensing, and business management.
Without your written authorization, we may be permitted or required by law to disclose your information in limited circumstances, including: to prevent a serious and imminent threat to your health or safety or that of another person; to report suspected abuse or neglect of a minor or dependent adult as required by Indiana law; in response to a valid court order or subpoena; or as otherwise required by federal or state law.
Any use or disclosure of your health information not described above — including most uses of psychotherapy notes, and any use for marketing purposes — requires your specific written authorization. You may revoke that authorization in writing at any time, except to the extent we have already relied on it.
To the extent our records include information protected under 42 CFR Part 2 (federal confidentiality protections for substance use disorder patient records), that information cannot be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a qualifying court order, and is subject to additional restrictions on redisclosure beyond standard HIPAA protections.
Indiana law may provide additional protections for certain mental health and counseling records beyond federal HIPAA requirements. Where state law is more protective of your privacy than HIPAA, the more protective standard applies.
We reserve the right to change the terms of this notice. Any revised notice will be effective for all health information we maintain, and will be made available upon request, in our office, and on this website.
To file a complaint with HHS: U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call 1-877-696-6775, or visit hhs.gov/hipaa/filing-a-complaint.