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HIPAA 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 it carefully:

Patient Rights To Privacy:

We are dedicated to maintaining the privacy of your personal health information as part of providing professional care. In addition, we are required to keep your information private under HIPAA
(Health Insurance Portability and Accountability Act of 1996) which protect patient health information, otherwise none as PHI. PHI is any distinguishing information that personally identifies you including your name, birthday, medical record number, and social security number. Under HIPAA Privacy Practice Policy, we are to uphold your information with the strictest integrity, confidentiality and security. This includes the storage, release and receipt of your PHI.

Health information obtained from you or other health care providers will be used to provide treatment. This information may also be used for business activities called healthcare operations. This includes providing you with a receipt for session payment, diagnosis, and type of treatment session provided if/when requested. A billing statement will not be sent to insurance companies unless specifically requested by you in conjunction with a signed authorization. This provides you control over the distribution of your own PHI to your insurer.

Any information disclosed, whether it’s to be obtained, disclosed or shared, can only be done with a signed release. We cannot disclose any information without your written permission.

Exceptions to maintaining the privacy of your health information due to legal/professional obligation are as follows:
• Serious threat to your health/safety or the health/safety of others. In cases such as these, only pertinent information will be granted to minimize or prevent such threats.
• Some lawsuits and/or legal court proceedings.
• Required by law enforcement officials (with legal documentation)
• Workers Compensation and similar benefit programs.
• If suspected of child abuse or neglect (your provider is a mandated reporter)

There are also other rare exceptions in which your information may be disclosed without your permission which include:
• Criminal investigation.
• Investigation by public health officials for diseases or injuries.
• Situations after death.
• Investigations by government or military officials.

If you have any questions or concerns in regards to your rights or privacy, please consult Nicole Chumsky, our privacy officer directly at (716) 906-3770.

Your Rights Regarding Your Healthcare Information:

As a client, you are entitled to request communication in a specific way or at a indicated location. For example, you may request that a clinician contact you by phone at home and not at work to schedule or cancel an appointment. We will accommodate your requests to the best of our ability.

You have the right to limit what is told to others involved in your care (or those involved in paying for your care), such as family members and/or friends.

You have the right to view the health information we have on our record, such as your medical and billing records. You may request a copy of these records for a fee (administrative time $60/hour, pro-rated and $.05/sheet). You are entitled to view the following information; the notations made regarding medication prescriptions and monitoring provided to you by another clinician, the modalities and frequencies of treatment sessions provided, results of clinical test/self-report forms/symptom monitoring sheets, written summary of diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. The only exception is the viewing of psychotherapy notes. There are laws governing the use of psychotherapy notes as they are intended to assist the psychotherapist only, having potential to be misinterpreted by others.

You have the right to accurate information in your health records. If you believe your records contain incorrect or missing information, you have the right to ask that amendments be made to our records. This request must be made in writing, indicating the reasons changes should be made which will be placed in your medical chart.

You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with Nicole Chumsky, founder of Be Embodied LLC, or with the Secretary of the Department of Health and Human Services (www.hhs.org). All complaints must be made in writing. Filing a complaint will not change the healthcare provided to you.

You have the right to copy this notice. A notice will be provided to you upon your initial visit. If amendments are made to this Notice of Privacy Practices document, changes will be posted in the waiting area and a new copy will be given.

To view New York State Law protecting patient rights, please visit https://www.health.ny.gov/professionals/patients/patient_rights/ (New York State Department of Health)

For further information on HIPAA regulations, or your right to privacy regarding healthcare information, please visit https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html (the US Department of Health and Human Services website).

A copy of the Standards for Privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164) of the OCR HIPAA Privacy Regulations (12-3-02, Rev 4-3-03) is available by request and is located with our front desk staff.

If you have any questions regarding this notice of health information privacy policies, please speak to Nicole Chumsky, privacy officer (716) 906-3770.

Are you interested in building your self-awareness and learning how to become more powerful in your life? Contact us today.

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