FEDERAL REGULATIONS
Privacy Practices, Terms and Conditions
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
HIPAA PRIVACY COMPLIANCE
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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Provider (Associates in Psychotherapy) may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care, and conducting heal care operations. Provider has established a policy to guard against unnecessary disclosure of your health information.
The following is a summary of the circumstances under which and purposes for which your health information may be used and disclosed:
To Provide Treatment. Provider may use your health information to provide care to you and disclose your health information to others who provide care to you. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Provider also may disclose your health care information to individuals outside of Provider involved in your care, such as your Primary Care Physician or the on-call psychiatrist.
To Obtain Payment. Provider may include your health information in invoices to collect payment from third parties for the care you may receive from Provider. For example, Provider may be required by your health insurer to provide or obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you.
To Conduct Health Care Operations. Provider may use and disclose health information for its own operations in order to facilitate the function of Provider and as necessary to provide quality care to all of Provider’s patients. Health care operations include activities such as quality assessment and improvement activities include: protocol development, case management and care coordination; contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment; professional review and performance evaluation; training programs including those in which students, trainees, or practitioners in health care learn under supervision; training of non-health care professionals; accreditation, certification, licensing, or credentialing activities; and review and auditing, including compliance reviews, medical reviews, legal services, and compliance programs.
For Appointment Reminders. At intake, you will choose how to receive appointments reminders, either by text, email or voicemail. Provider’s electronic health record, InSync, may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care with Provider.
SMS and Text Messaging - Carriers are not liable for delayed or undelivered messages. If you would like to change your reminder type or opt out, please contact Provider at 608-752-7255. For SMS and text messages, message and data rates may apply.
When Legally Required. Provider will disclose your health information when it is required to do so by any Federal, State, or local law.
To Report Abuse, Neglect, or Domestic Violence. Provider is allowed top notify government authorities if Provider believes a patient is the victim of abuse, neglect, or domestic violence. Provider will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities. Provider may disclose your health information to a health oversight agency for activities including: audits, civil, administrative, or criminal investigations; inspections; licensure or disciplinary action. Provider, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to you receipt of health care or public benefits.
In Connection with Judicial and Administrative Proceedings. As permitted or required by State law, Provider may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other protecting your health information.
For Law Enforcement Purposes. As permitted or required by State law, Provider may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
In the Event of a Serious Threat to Health or Safety. Provider may, consistent with applicable law and ethical standards of conduct, disclosure your health information if Provider, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize Provider to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker’s Compensation. Provider may release your health information for worker’s compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other what is stated above, Associates in Psychotherapy will not disclose your health information other than with your written authorization. If you or your representative authorizes Provider to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Provider maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Provider’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Provider is not required to agree to your request. If you wish to make a request for restrictions, please contact: Jennifer Litscher, Clinic Coordinator, at 608-752-7255.
Right to Receive Confidential Communications. You have the right to request that Provider communicate with you in a certain way. For example, you may ask that Provider only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact: Jennifer Litscher, Office Coordinator, at 608-752-7255. Provider will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Jennifer Litscher, Office Coordinator, at 608-752-7255. If you request a copy of your health information, Provider may charge a reasonable fee for copying and assembling costs associated with your request.
Right to Amend your Health Information. You or your representative have the right to request that Provider amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Provider. A request for an amendment of records must be made in writing to Jennifer Litscher, Clinic Coordinator, c/o Associates in Psychotherapy, 4700 Dresser Dr, Ste 100 Janesville, WI 53545. Provider may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Provider, if the records you are requesting are not part of Provider’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, of if, in the opinion of Provider, the records containing your health information are accurate and complete.
Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Provider for certain purposes, which may include disclosures authorized by law. The request for an accounting must be made in writing to Jennifer Litscher, Clinic Coordinator, c/o Associates in Psychotherapy, 4700 Dresser Dr Ste 100, Janesville, WI 53545. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Provider will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact Jennifer Litscher, Clinic Coordinator, at 608-752-7255.
DUTIES OF ASSOCIATES IN PSYCHOTHERAPY
Provider is required by law to maintain the privacy of your health information and to provide you and your representative this Notice of its duties and privacy practices. Provider is required to abide by the terms of this Notice as may be amended from time to time. Provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Provider makes a material change to this Notice, Provider will provide a copy of the revised Notice to your or your appointed representative. You or your representative have the right to express complaints to Provider and to the Secretary of Health and Human Services, if you or your representative believe that your privacy rights have been violated. Provider encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
CONTACT PERSON
Provider has designated Jennifer Litscher, Clinic Coordinator, as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. If you have any questions regarding this Notice, you may contact this person at Associates in Psychotherapy, 4700 Dresser Dr, Ste 100, Janesville, WI 53545, at 608-752-7255.
EFFECTIVE DATE
This Notice is effective April 1, 2025.