PRIVACY PRACTICES:
NOTICE OF PRIVACY PRACTICES FOR HANNAH POLLOK, LMFT

This notice describes your rights and how your Personal Health Information (PHI) may be used and disclosed and how you can access this information. Please take time to carefully review this document.

You have the right to: get a copy of your paper medical record, correct your paper medical record, request confidential communication, ask me to limit the information I share, get a list of those with whom I’ve shared your information, get a copy of this privacy notice, choose someone to act for you, and file a complaint if you believe your privacy rights have been violated.

You have some choices in the way that I use and share information as I: tell family and friends about your condition; provide disaster relief; include you in a hospital directory; provide mental health care; market our services and sell your information; and raise funds.

I may use and share your information as I: treat you; run my organization; bill for your services; help with public health and safety issues; do research; comply with the law; respond to organ and tissue donation requests; work with a medical examiner or funeral director; address workers’ compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

YOUR RIGHTS

You can for a paper copy of your medical record and other health information we have about you. I will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

You can ask me to correct health information about you that you think is incorrect or incomplete. I may say no to your request, but I’ll tell you why in writing within 60 days. You can request that I contact you in a specific way (for example, cell phone or office phone) or to send mail to a different address. I will say yes to all reasonable requests. 

You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and may say no if it would affect your care. 

Since you pay for a service or health care item out-of-pocket in full, I do not share that information for the purpose of payment or our operations with your health insurer. If part or all of your service fee is paid by a third-party, I may use and share your information to confirm eligibility for services and to ensure proper payment for services rendered.

You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked that I make). I’ll provide one list per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. 

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly. 

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. I will make sure the person has this authority and can act for you before we take any action. 

You can complain if you feel I have violated your rights by contacting us using the information above. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to

200 Independence Avenue, S.W., Washington, D.C. 20201, 

calling 1-877-696-6775, 

or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. 

I will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described in the following, talk to me. Tell me what you want done, and I will follow your instructions. In these cases, you have both the right and choice to tell us to: share information with your family, close friends, or others involved in your care; share information in a disaster relief situation; include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, I never share your PHI unless you give me written permission: marketing purposes, sale of your information, and most sharing of psychotherapy notes. I will not sell your PHI unless you give me written permission. In the case of fundraising, I may contact you for fundraising efforts, but you can tell me not to contact you again.

USES AND DISCLOSURES

I typically use or share your health information in the following ways: 

- With other professionals who are treating you (For example, a doctor treating you for an injury asks another doctor about your overall health condition).

- I can use and share your health information to run my practice, improve your care, and contact you when necessary (For example, I use health information about you to manage your treatment and services). 

I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. I must meet many conditions in the law before I can share your information for these purposes. I can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; preventing or reducing a serious threat to anyone’s health or safety. For more information, visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.  I can use or share your information for health research. I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. I can share health information about you with organ procurement organizations. I can share health information with a coroner, medical examiner, or funeral director when an individual dies. I can use or share health information about you for worker’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services. I can share health information about you in response to a court or administrative order, or in response to a subpoena.

I am required by law to maintain the privacy and security of your PHI. I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. I must follow the duties and privacy practices described in this notice and give you a copy of it. I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind. 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available online and upon request. 

Effective Date of this Notice: JUNE 22, 2024