Rights and Protections
NOTICE OF PRIVACY PRACTICES (HIPAA)
This notice describes how your protected health information (PHI) may be used and disclosed and how you can access this information. Please review it carefully. Protecting our patients' privacy has always been important to this practice. State and federal law, the Health Insurance Portability and Accountability Act (HIPAA) requires us to inform you of our policy. At Ironwood Counseling and Psychological Services, PLLC we are very careful to keep your health information secure and confidential. This law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice.
Disclosure of your PHI not requiring your authorization
* The law permits us to use or disclose your health information to those involved in your treatment; for example, a review of your file by a specialist doctor whom we may involve in your care.
* We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.
* We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.
* We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.
* We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering service or with the person who answers the telephone. In an emergency, we may disclose your health information to a family member or another person responsible for your care.
* We may release some or all of your health information when required by law.
Disclosure of your PHI requiring your authorization
For uses and disclosures of your protected health information beyond the above excepted purposes, we are required to have your written authorization, except as otherwise required or permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing.
Examples of uses or disclosures that would require your written authorization include, but are not limited to, the following:
* A request to provide your protected health information to a family member, employer, attorney for use in a civil litigation claim, disability provider, etc.
* Most uses or disclosures of psychotherapy notes, uses or disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI.
* A request to provide PHI to another individual or facility, where no exception from the written authorization requirement applies.
Your health record
Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. You will be notified if there is any breach of your PHI that was unsecured.
Additionally
* You have the right to transfer copies of your health information to another practice. You have the right to see or receive a copy of any of your PHI. Any personal requests for copies of your PHI will be reviewed and responded to by your provider within 30 business days.
* You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove or alter earlier documents, but will add new information.
* You have the right to restrict certain disclosures of your PHI to a health plan if you choose to pay out of pocket in full for our services.
* You have the right to receive a copy of this notice. If we change any of the details of this notice, we will notify you of the changes in writing.
* You may file a complaint with the Department of Health and Human Services. However, before filing a complaint, or for more information or assistance regarding your health record, please contact our office using the information above.
* If this practice is ever sold, your information will become the property of the new owner.
You may exercise any of the rights described above in person or by contacting our office at (480) 988-5003 or by fax (480) 988-9799 and asking for the office manager (Heidi Dinehart). Any complaints, requests, or questions must be received in writing. You will not be retaliated against for filing a complaint. As we will need to contact you from time to time, we will use whatever address or telephone number you prefer.
NO SURPRISES ACT
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing. “This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out of network provider or facility, the most the provider or facility may bill you is your plan’s in network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must: o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact: Ironwood Counseling and Psychological Services at 480-988-5003.
Visit https://www.cms.gov/nosurprises
OMB Control Number: 0938-1401