THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health
information.
I. The Wild Goose Counseling LLC (and any associated private contractors) pledge regarding your health care information:
We understand that health information about you and your health care is personal. Wild Goose Counseling LLC is committed to protecting health information about you. We will create an electronic medical record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by our mental health care practice and tells you about the ways in which your counselor may use and disclose health information about you. This notice also provides you with information about your rights to the health information we keep about you, and describes certain obligations we have regarding the use and disclosure of your health information.
Your counselor is required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
Your counselor may change the terms of this Notice, and such changes will apply to all information that Wild Goose Counseling LLC has about you.  If changes take place, the new Notice will be available upon request, via paper copies at our office and also available to you on our website.
II. HOW WILD GOOSE COUNSELING LLC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that Wild Goose Counseling LLC may use and disclose health information. Not every use or specific disclosure within a category will be listed, however, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment, Payment, or Health Care Operations:
Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization in order to carry out the health care provider’s own treatment, payment, or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider.
For example, if a Wild Goose clinician were to consult with an Emergency Room Physician when you are there for a mental health crisis, we would be permitted to use and disclose your health information, with or without your permission, in order to assist the physician in correct diagnosis and treatment of your mental health condition.  Another example of this would be disclosure of your diagnosis to your insurance provider, should you wish us to bill your insurance company.
Disclosures for treatment purposes are not limited to the minimum necessary standard. This is because therapists and other health care providers sometimes need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes:
If you are involved in a lawsuit, counselors with Wild Goose may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. Please note that if this
occurs, we will first make efforts to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes are kept by the counselors at Wild Goose Counseling LLC.
Such notes are defined in 45 CFR §164.501.  Any use or disclosure of such notes requires your authorization, unless the use or disclosure is:
a. For use in treating you.
b. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For use in defending the counselor in legal proceedings instituted by you, should such a thing ever occur.
d. For use by the Secretary of Health and Human Services, should there ever be an investigation of our compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of yourself or others.
2. As a psychotherapist, your counselor will not use or disclose your PHI for marketing purposes.
3. As a psychotherapist, your counselor will not sell your PHI in the regular course of business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, Wild Goose Counseling LLC can use and disclose your PHI without your authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order.
5. For law enforcement purposes, including reporting crimes occurring on our premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety
of those working within or housed in correctional institutions.
9. For workers’ compensation purposes, we may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives or other/new health care services or benefits that we offer.
11. If you tell your counselor that you have HIV (Human Immunodeficiency Virus) or AIDS (Acquired Immune Deficiency Syndrome), we may be required by law to inform the Department of Public Health’s Office of Epidemiology. The Office of Epidemiology may then contact any sexual partners you have had to inform them that they may have been exposed to the disease.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family (or friends or others) are usually only done at your express request. It is our policy to ask for your permission whenever possible before engaging in disclosure to family and friends, as your confidentiality and privacy is important to us. However, your counselor may have to disclose some of your health care information if the family member is involved in the payment of your health care, OR if you are a minor under the care of your parent or guardian and they request your health information, OR if there is an emergency situation and your safety is at risk.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask Wild Goose Counseling LLC not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request. We may charge a reasonable, cost-based fee for doing so.
5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but, if so, we will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
Complaints: If you have questions or feel your privacy rights have been violated you can contact the Department Privacy Official by calling 907-465-2150, or by writing to
State of Alaska, DHSS Privacy Official,
PO Box 110650, Juneau, AK 99811-0650,
or by e-mailing PrivacyOfficial@health.state.ak.us.
You can also complain to the federal government Secretary of Health and Human Services (HHS) or to the HHS Office of Civil Rights. Your health care services will not be affected by any complaint made to the Department Privacy Official, Secretary of Health and Human Services or Office of Civil Rights.
This notice is effective for clients of Wild Goose Counseling, LLC, as of June 1, 2017.