Exeter Counseling Center, PLLC
Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY

Your health record contains personal information about you and your health. This is informationabout you that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. It is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA, the HIPPA Privacy and
Security Rules, and the appropriate professional code of ethics. It also describes your rightsregarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provided you with a copy of the revised Notice of Privacy Practices by positing a copy on our website, providing you one at your next appointment or
sending you a copy in the mail upon request.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment
Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to other consultants only with your authorization.

For Payment
We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of paymentrelated activities are: making a
determination of eligibility of coverage for insurance benefits, processing claims with your insurance company, and reviewing services provided to you to determine medical necessity or other utilization review activities. If it becomes necessary to use collection processes due to a lack of payment for services, we will only disclose the minimum amount of PHI necessary for the purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, appointment reminders, quality assessment activities, employee review activities, licensing, and/or conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training purposes, PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Humans Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Disclosures Without Authorization
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and professional ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. As licensed mental health professionals, it is our practice to adhere to the more stringent privacy requirements for disclosures without an authorization.

Child Abuse or Neglect. We may disclose PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings.
We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order, or similar process.

Deceased Patients
We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or for payment for services prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies
We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care
We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors and peer review organizations performing
utilization and quality control).

Law Enforcement. We may disclose PHI to law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order, or similar document, for the purpose of identifying a suspect, material witness, or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions
We may review requests from US Military command authorities if you have served as a member of the armed forces, from authorized officials for national security and intelligence reasons, and from the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws, and the need to prevent serious harm.

Public Health
If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety
We may disclose your PHI, if necessary, to prevent or lessen a serious and imminent threat to health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research
PHI may only be disclosed after a special approval process or with your authorization.

Verbal Permission
We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

Disclosures with Written Authorization
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI that we maintain for you. To exercise any of these rights, please submit a request in writing to our Privacy Officer, Roz Novak Houston, MSW, 163 Water St, Exeter, NH 03833.

Right of Access to Inspect and Copy
You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

Right to Amend
If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and
will provide you with a copy. Please contact our Privacy Officer if you have any questions.

Right to Accounting of Disclosures
You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable feel if you request more than one accounting in any 12-month period.

Right to Request Restrictions
You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for the purposes of carrying out payment or healthcare operations, and the PHI pertains to health care items or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

Right to Request Confidential Communication
You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

Breach Notification
If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

Right to a Copy of this Notice
You have the right to a copy of this notice. You will be asked to sign an acknowledgement that you received this notice of privacy practices.

COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer, Roz Novak Houston, MSW, 163 Water St, Exeter, NH 03833, or with the Secretary of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201, or by calling (202)619-0257. We will not in any way limit your care or take actions against you for filing a complaint.

If you have any questions regarding this notice or our health information privacy policies, please contact your therapist by phone at (603)778-7433.

The effective date of this Notice is January, 2017

LOCATIONS

24 Front Street, Exeter, NH 03833
Deborah Addario, MSW, LICSW
Richard Warren, Ph.D.

13 Jenkins Court, Durham, NH 03824
Jeanne Allen, LICSW, C-CATODSW