HIPAA PRIVACY POLICY ACKNOWLEDGMENT/AGREEMENT

This notice describes how your health information, as a patient of Psychiatric and Psychological Affiliates of Scottsdale, PLC, may be used and disclosed, as well as how you can get access to your health information. This is required by the Privacy Regulations created as a result of the "Health Insurance Portability and Accountability Act" of 1996 (HIPAA).

Our commitment to your privacy: Your clinician is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following information:

Use and disclosure of your health information in certain special circumstances: (The following circumstances may require your clinician to use or disclose your health information.)

  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 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 and protect from harm.
  5. If you are a member of the U.S. or a 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 custody of a law enforcement official.
  8. For Workers Compensations and similar programs.

Your rights regarding your health information:

  1. Communications: You can request that your clinician 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 at 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 information to only certain individuals involved in your care or the payment of 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 or when the information is necessary to treat you.
  3. 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 record and billing records, but not including psychotherapy notes. You must submit your request in writing to your clinician at: 14301 N. 87th Street, Suite 112, Scottsdale, AZ 85260.
  4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept for your clinician. To request an amendment, your request must be made in writing and submitted to your clinician at: 14301 N. 87th Street, Suite 112, Scottsdale, AZ 85260.
  5. Filing a Grievance: You have the right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with your clinician or with the Secretary of the Department of Health and Human Services. To file a complaint with your clinician, please submit in writing to your clinician at: 14301 N. 87th Street, Suite 112, Scottsdale, AZ 85260. Please note, you will not be penalized for filing a complaint.
  6. Right to a copy of this notice at any time: You are entitled to receive a copy of this Notice of Privacy Policies. You may ask us to give you a copy at any time. To obtain a copy of this notice, contact your clinician's front reception desk.
  7. Right to provide an authorization for other uses and disclosures: your clinician 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 regarding this notice or our Health Information Privacy Policies, please contact your physician/clinician at 480.609.0001.