Notice of Privacy Practices
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures of Information Requiring Your Authorization or Consent
As a rule, Gray MD Psychiatry, LLC will not disclose information about you or that you are my patient without your written consent.
II. Limits of Confidentiality:
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality. Health care providers are legally allowed to use or disclose records or information without your consent for treatment, payment, and health care operations purposes. If you wish to receive mental health services from me, you must sign the consent form within the Charm Portal, indicating that you understand and
consent to accept my policies about confidentiality and its limits.
When releasing information, I will release the least amount of information necessary to achieve the intended outcome. Health care providers involved in your medical care currently or in the past can speak with each other or share information regarding your medical care without written consent.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required:
· Emergency If you are involved in a life-threatening emergency, and I cannot ask your permission, I will share information if I believe you would have wanted me to do so or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Virginia law to report the matter immediately to the Virginia Department of Social Services
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services
· Health Oversight: Virginia law requires that I report misconduct by a health care provider. By policy, I also reserve the right to report misconduct by health care providers of other professions. If you are yourself a health care provider, I am required by law to report to your licensing board if I believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records for investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court proceeding, and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so that you (or your attorney ) can file a motion to quash (block) the subpoena
· Serious Threat to Health or Safety: Under Virginia law, if I am engaged in my professional duties, and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s) or the parent or guardian of the potential victim(s), if, under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or law enforcement officer.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant health information to you, your employer, the insurer, or a certified rehabilitation provider.
Other uses and disclosures of information not covered by this Notice or by the laws that apply to me will be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on specific uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me:
1)What information do you want to limit
2)Whether you want to limit my use, disclosure or both
3)To whom you want the limits to apply
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
· Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process
. Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal or administrative proceeding.
· Right to Amend – If you feel that the protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
· Right to a copy of this Notice – You have the right to a paper copy of this Notice. You may ask me to give you a copy of this Notice at any time. Changes to this Notice: I reserve the right to change my policies and/or change this Notice and make the changed Notice effective for medical information I already have about you and any information I receive in the future. The Notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the current Notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
Effective Date: 9/18/19
Patient’s Acknowledgement of Receipt of Notice of Privacy Practices
Please sign, print your name, and date this acknowledgment form.
I have been provided a copy of Gray MD Psychiatry, LLC Notice of Privacy Practices.
I understand that I may ask questions about them at any time in the future.
I consent to accept these policies as a condition of receiving mental health services.
please sign consent forms in the patient portal under questionnaires