Susan Cummings Nicholson, PhD, LCSW, BCD
Adult and Couples Teletherapy drsusancummingsnicholson.com
Phone: 757-873-3401 Email: firstname.lastname@example.org Fax: 757-223-1165
Mailing address: 25 Hidenwood Shopping Center #6364, Newport News, VA 23606
Practice address: 739 Thimble Shoals Blvd. Suite 704-7, Newport News, VA 23606
NOTICE OF PRIVACY PRACTICES
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.
I am required by law to maintain the privacy of your health information. I am also required to give you this notice about required privacy practices, legal obligations and your rights concerning your health information. I will follow the privacy practices that are described in this notice. If this notice is amended, I will make available the amended notice for your information. I will be happy to answer any questions you may have about my privacy practices or to provide you with additional copies of this notice upon request.
I. Uses and disclosures of protected health information (PHI)
A. Permissible uses and disclosures without your written authorization. Your provider may use and disclose your PHI without your written authorization for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures of your mental health information that are legally permissible.
- Treatment: Your provider may use and disclose your PHI to other clinicians involved in your care, in order to better provide integrated treatment to you. For example, your provider may discuss your diagnosis and treatment plan with your psychiatrist, family physician or nurse practitioner. In addition, your provider may disclose your PHI to other health care providers, in order to provide you with appropriate care and continued treatment.
- Payment: Your provider may use or disclose your PHI for the purpose of determining coverage, billing, claims management and reimbursement. For example, a bill sent to your health insurer may include some information about your treatment plan and progress, so that the insurer will pay for the treatment. Your provider may also inform your health plan about a treatment you are going to receive, in order to determine whether the plan will cover the treatment.
- Health care options: Your provider may use and disclose your PHI in connection with health care options including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities. For example, your provider may disclose disguised information about your work together for training purposes.
- Required or permitted by law: Your provider may use or disclose your PHI when required or permitted to do so by law. For example, your provider may disclose your PHI to appropriate authorities, if she reasonably believes that you are a possible victim of abuse, neglect, domestic violence or the possible victim of other crimes. In addition, your provider may disclose your PHI to the extent necessary, to avert a serious threat to your health or safety, or the health or safety of others. Other disclosures permitted or required by law include the following: Disclosures for public health activities, health oversight activities (including disclosures to state or federal agencies authorized to access your PHI), disclosures to judicial and law enforcement officials in response to a court order or other lawful process, disclosures for research when approved by an Institutional Review Board, disclosures for workman’s compensation claims, and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions, as authorized by law.
B. Permissible uses and disclosures that may be made without your authorization, but for which you have an opportunity to object.
- Family and other persons involved in your care. Your provider may use or disclose your PHI to notify or assist in the notification (including identifying or locating), of your personal representative, or another person responsible for your care, location, general condition, or matters after your death. If you are present, your provider will provide you with an opportunity to object prior to such uses or disclosures. In the event of your incapacity or in emergency circumstances, your provider may disclose your PHI consistent with your prior expressed preference, and in your best interest, as determined by professional judgment. Your provider will also use professional judgment and experience to make reasonable inferences of your best interest, in allowing another person access to your PHI regarding your treatment.
- Disaster relief efforts. Your provider may use or disclose your PHI to a public or private entity, authorized by law or its charter, to assist in disaster relief efforts, for the purpose of coordinating notification of family members of your location, general condition, or death.
C. Uses and disclosures regarding your written authorization.
- Psychotherapy notes. Your provider will not disclose any notes made about conversations during your therapy sessions, which have been kept separate from your medical record, without your written permission except as permitted by law.
- Other uses and disclosures. Uses and disclosures, other than those described in this notice, will only be made with your written authorization. For example, you will need to sign an authorization form before your provider can send your PHI to your life insurance company or to your attorney. You may revoke any such authorization at any time, by providing your provider with written notification of such revocation.
II. Your individual rights
- Right to inspect and copy. You may request access to your medical records and billing records maintained by your provider, in order to inspect and request copies of the records. All requests for access must be made in writing to your provider. Under limited circumstances, your provider may deny access to your records. Your provider may charge a fee for the cost of copying and sending you any records requested.
- Right to alternative communications. You may request and your provider will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
- Right to request restrictions. You have the right to request a restriction on your PHI that your provider uses or discloses for treatment, payment or healthcare operations. You must request any such restriction in writing, addressed to your specific provider at mailing address: 25 Hidenwood Shopping Center #6364, Newport News, Virginia 23606.
- Right to accounting of disclosures. Upon written request, you may obtain an accounting of disclosure of your PHI, made by your provider in the last six years, subject to certain restrictions and limitations.
- Right to request amendment. You have the right to request that your provider amend your PHI. Your request must be in writing and should explain why the information should be amended. Your provider may deny your request under certain circumstances.
- Right to obtain notice. You have the right to obtain a paper copy of this notice by downloading it from your provider’s website at www.drsusancummingsnicholson.com or by requesting a copy from your provider.
- Right to receive notification of a breach. Your provider is required to notify you if she discovers a breach of your unsecured PHI, according to requirements under federal law.
- Questions and complaints. If you desire further information about your privacy rights or are concerned that your provider has violated your privacy rights, please contact your specific provider. Any written communication is to be addressed to your provider at 25 Hidenwood Shopping Center #6364, Newport News, Virginia 23606. You may also file a written complaint with the Director, Office for Civil Rights of the US Department of Health and Human Services. Your provider will not retaliate against you, if you file a complaint.
III. Effective date and changes to this notice
- Effective date. This notice is effective on May 1, 2022.
- Changes to this notice. If your provider changes any of the terms of this notice at any time, she may make the new notice terms effective for all PHI that she maintains, including any information created or received prior to issuing the new notice. If a change occurs, your provider will post the revised notice on her website at www.drsusancummingsnicholson.com. You may also obtain a copy of any revised notice by asking your provider directly.