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