Our Mission is to be emotionally and cognitively focused for each personal interaction and to conduct each of our interactions with respect, dignity and integrity. By doing this, we will promote health, growth, and wholeness
Advanced Brain and Body Clinic, PLLC
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.
You will be asked to provide written consent and authorization for specific uses of information about yourself.
If you have any questions about this Notice, please contact our office staff.
The Advanced Brian and Body Clinic, PLLC (ABBC) is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. This Notice of Information Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. These Practices are effective on April 14, 2003 and are not necessarily retroactive to prior actions of ABBC.
“Protected health information” (PHI) is information about you, including demographic and mental health information, that relates to your past, present, or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Information Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Notice of substantive revisions and/or modifications to the ABBC will be posted in the waiting rooms at ABBC. Upon your request, we will provide you with any revised Notice of Information Practices in person or by calling the office and requesting that a revised copy be sent to you in the mail. You may also ask for one at the time of your appointment.
Section 1. Uses and Disclosures of Protected Health Information (PHI)
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent/Authorization
You will be asked to complete and sign a ABBC Patient Information, Consent to Treatment and Authorization for Use of PHI form. Once you have explicitly authorized the use and disclosure of your protected health information for treatment, payment, and health care operations, we may use or disclose your protected health information as described in this Section 1.
Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make once you have signed this form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.
Treatment: We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information to other health care providers who may be treating you when we have the necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to another health care provider to whom you have been referred to ensure that they have the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another health care provider (e.g., a specialist or laboratory) who, at the request of your ABBC provider, becomes involved in your care by providing assistance with your health care diagnosis or treatment. If you believe you need a Language Interpreter, please request a Consent Form for Use of Language Interpreter to complete.
Payment: Your protected health information will be used to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services, we recommend. Examples include, but are not limited to: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, providing psychiatric and other mental health records, which may include psychiatric and psychotherapy notes, to your insurer at the request of your insurer, and undertaking utilization review activities. Generalized summaries of psychiatric medication management, supportive therapy, and generalized summaries of psychotherapy notes may be released unless specifically prohibited by you. Obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. By signing the ABBC Patient Information, Consent and Authorization form you will be giving us explicit permission to use your records in this manner, until such time as you revoke this authorization in writing to as provided below.
Healthcare Operations: We may use or disclose your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities.
For example, we may also call you by name in the waiting room when your provider is ready to see you. We may also use or disclose your protected health information to contact you to remind you of your appointment. For example, we may call your contact phone number(s) and leave a message or email you at the email address you provide us, to remind you of the time and date of your next appointment at ABBC. If you send ABBC an email, you are authorizing ABBC to use email to correspond with you using the Reply Address in that email.
We will share your protected health information with third party “business associates” that perform various activities (e.g., transcription and collection services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
Uses and Disclosures of Protected Health Information Based upon Your Specific Written Authorization
Other uses and disclosures of your protected health information will be made only with your specific written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that ABBC has taken an action in reliance on the use or disclosure indicated in the authorization.
ABBC can disclose PHI containing psychiatric and psychotherapy notes unless specifically prohibited by you. However, you may not be entitled to receive a copy of such notes under some conditions. Requests must be made on the ABBC Request for Release of Psychotherapy Information & Authorization form. Generalized summaries of psychiatric medication management supportive therapy and generalized summaries of psychotherapy notes may be released as well, unless specifically prohibited by you, as outlined in the Payment paragraph above. If you are being treated under a Worker Compensation claim PHI may be released as appropriate. “Psychotherapy Notes” may include Psychiatric and/or Psychotherapy notes and/or Evaluations. Should you opt not to disclose this information, it may result in loss of care.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless we have specific permission from you, on an ABBC Psychotherapy ROI, we are prohibited from disclosing any PHI in any form with family members, relatives, or close friends who may be involved in your care. The exception to this would be an emergent situation as outlined below. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, we shall try to obtain your consent as soon as reasonably possible after the delivery of treatment. If we are required by law to treat you and we have attempted to obtain your consent but is unable to obtain your consent, we may still use or disclose your protected health information to treat you. We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so due to substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object
We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury, or disability. We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to Court Order.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or the health or safety of another person or the public.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Section 2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you obtain or request the release to others a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that we use for making decisions about you. Requests must be made on the ABBC Request for Release of Information & Authorization form. Other formats may not be allowed. We may charge you or a third party for this service, payable in advance.
Under federal law, however, you may not necessarily have copies of the following records; psychotherapy and psychiatric progress notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. Please contact our Privacy Contact if you have questions about access to your PHI.
You have the right to request a restriction of your protected health information. This means you may request us in writing not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Information Practices.
ABBC is not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If we do agree to the requested restriction, we may not use or disclose your protected health information unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with us. Your request must state the specific restriction requested and to whom you want the restriction to apply. You may request restriction by completing the ABBC Request for Use/Restriction of PHI form and making an appointment with ABBC's Privacy Contact noted below.
You may have the right to have ABBC amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact if you have questions about amending your medical record. You may request an amendment by completing the ABBC Request for Amendment of PHI form and making an appointment with ABBC’s Privacy Contact noted below.
You have the right to receive an accounting of certain disclosures we have made of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Information Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations as noted below. You may request an amendment by completing the ABBC Request for Accounting of PHI Disclosure form and making an appointment with ABBC’s Privacy Contact noted below.
You are entitled to an accounting of the use and disclosures of protected health information for occurrences other than for treatment, payment, or health care operations. ABBC is not required to account disclosures for referring physicians, consults, or specialty procedures that are a result of an indirect patient relationship by another provider. Also, disclosures for law enforcement purposes or that are required by statutory law and that do not need an authorization are not required to be accounted. The accounting will also not include disclosures to the individual requesting the accounting, for national security or intelligence purposes, to correctional institutions, law enforcement officials, or that occurred prior to April 14, 2003.
ABBC has sixty (60) days to comply with this request and must be granted a thirty (30) day extension with a written explanation regarding the reason for the delay. We must also provide the accounting of PHI without charge for requests in any 12-month period. For more than one request in a 12-month period, we may charge for printing or copying of PHI. Accountings will be mailed to the requestor by regular U.S. Mail to the address on the ABBC Request for Accounting of PHI Disclosure.
Section 3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Candi Tucker at 612-682-4912, ext. 407 for further information about the complaint process.
Section 4. You are part of the ABBC Privacy Team
Who and what you see at the Advanced Brain and Body Clinic, PLLC, as well as what you may overhear while you are at the Clinic must “stay here.” Just as you would not want someone discussing that you, your family member or friend, are a patient at the ABBC clinic, neither should you tell others who you see receiving care.
You have the right to obtain a copy of this Notice from us, upon request.
This notice was published and becomes effective on April 01, 2021.
Version: 2021
We accept your direct communication through the portal! Please log in to send direct messages to our providers or office staff.