This notice describes how medical information about you may be used and disclosed, and how you can get access to your health information. Please Read Carefully.
Protecting Your Privacy
Protecting your privacy and your medical information is at the core of our business. We recognize our legal and ethical obligation to keep your information secure and confidential whether it be orally, on paper, or in an electronic form.
How we might use your medical information
We will use your medical information for providing treatment, such as by looking at your records to use your medical history for current treatment; and/or payment, such as when a payer requests copies of our medical information to pay a claim; and/or for healthcare operations, such as for internal auditing. We may contact you to help provide you with information concerning your health. We may also contact you to remind you of an upcoming appointment, taking care not to reveal any of your medical information. You have a right to ask us not to contact you using this method. I understand that as a part of my healthcare, Stable Transformation originates and maintains health records describing my health history, symptoms, examination on test results, diagnosis, treatment, and any plans for future care of treatment for up to seven years after the date of my last session at Stable Transformation. I understand that this information serves as a basis for planning my care and treatment, a means of communication among the many health professionals who contribute to my care, a means by which a third-party payer can verify that services billed were actually provided, and a tool for routine healthcare operations such as assessing quality and reviewing the competence
of healthcare professionals.
Use and disclosure for your health information in certain special circumstances; the following circumstances may also require us to use or disclose your health information without your consent or authorization:
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
5. If you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.
6. To federal officials for intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
8. For workers compensation and similar programs
Your rights regarding your health information
1. You can request that Stable Transformation, LLC. communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have a right to ask for complete accounting of disclosures that were not authorized or otherwise permitted as listed above. You may revoke your authorization to disclose your medical information at any time.
4. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. In order to receive a copy of your records, Stable Transformation will charge you fifty cents ($.50) per page. You must submit your request in writing and in person to Stable Transformation, LLC., Attn: Office Manager. Before receiving your records, you must make an appointment with your therapist, so he or she can go over your records with you, in case you have any questions.
5. You may ask to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for Stable Transformation. To request an amendment, your request must be made in writing and submitted to Stable Transformation, LLC., Attn: Office manager. You must provide us with a reason that supports your request for amendment.
6. You have a right to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. Stable Transformation reserves the right to change their notice and practices and if the terms do change, you may obtain a revised Notice by contacting Stable Transformation, LLC. by mail or by asking a therapist.
7. You have a right to file a complaint. If you believe that your privacy rights have been violated, you may file a complaint with (1) Stable Transformation, LLC or with (2) the Secretary of the Department of Health and Human Services. Both addresses are provided at the bottom of this form. All complaints must be submitted in writing. To file a complaint with Stable Transformation, contact the Office Manager. You will not be penalized for filing a complaint.
8. You have a right to provide an authorization for other uses and disclosures. Stable Transformation, LLC. will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions about this notice or our health information privacy practices, please contact Stable Transformation, LLC.