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Days of Our Lives
Legal · HIPAA

Notice of Privacy Practices

Effective date: [TO BE SET]. Last updated: [TO BE SET].

Template notice for agency: This Notice of Privacy Practices is a working draft based on the requirements at 45 CFR § 164.520. It must be reviewed and customized by qualified counsel before use. Provide it to every new client at intake and obtain written acknowledgment.

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.

Our Commitment to Your Privacy

Days of Our Lives is required by law to maintain the privacy of your protected health information ("PHI"), to provide you this notice of our legal duties and privacy practices with respect to PHI, and to follow the terms of the notice currently in effect.

How We May Use and Disclose Your PHI

For Treatment

We may use and disclose your PHI to provide, coordinate, or manage your behavioral health care and any related services. For example, your clinician may share information with another provider who is also treating you.

For Payment

We may use and disclose your PHI to bill and collect payment for the services we provide — including to your insurance carrier, Medicaid managed care organization, or Medicare.

For Health Care Operations

We may use and disclose PHI for activities necessary to operate our agency, such as quality assessment, training, accreditation, licensing, and case management.

Additional Permitted Uses and Disclosures

We may use or disclose PHI without your authorization in limited circumstances permitted or required by law, including:

  • When required by federal, state, or local law
  • For public health activities, including reporting communicable diseases
  • To report suspected abuse, neglect, or domestic violence
  • For health oversight activities, such as audits and inspections
  • In response to a court order, subpoena, or other lawful process
  • To law enforcement, in limited circumstances
  • To coroners, medical examiners, or funeral directors
  • For organ and tissue donation purposes
  • For approved research with appropriate safeguards
  • To avert a serious and imminent threat to health or safety
  • For specialized government functions, such as military, national security, or correctional purposes
  • For workers' compensation claims as authorized by state law

Substance Use Disorder Records (42 CFR Part 2)

Records relating to substance use disorder treatment are subject to additional protections under federal law (42 CFR Part 2). With limited exceptions, we may not disclose those records without your written consent.

Uses and Disclosures Requiring Your Written Authorization

Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and any sale of your PHI require your written authorization. You may revoke that authorization in writing at any time, except to the extent we have already acted on it.

Your Rights

  • Access: You have the right to inspect and obtain a copy of your PHI, with limited exceptions.
  • Amendment: You may request an amendment to your PHI if you believe it is incorrect or incomplete.
  • Accounting of Disclosures: You may request a list of certain disclosures we have made of your PHI.
  • Restrictions: You may request a restriction on how we use or disclose your PHI. We are not required to agree to every requested restriction.
  • Confidential Communications: You may request that we communicate with you in a specific way (for example, by mail rather than phone) or at a specific location.
  • Paper Copy: You have the right to receive a paper copy of this notice on request, even if you have agreed to receive it electronically.
  • Breach Notification: You have the right to be notified following a breach of your unsecured PHI.

Our Duties

  • We are required by law to maintain the privacy of your PHI and to provide you with this notice of our duties and privacy practices.
  • We must abide by the terms of the notice currently in effect.
  • We reserve the right to change our practices and the terms of this notice and to make the new terms effective for all PHI we maintain.
  • If we make material changes, we will post the revised notice on our website and make paper copies available at our office.

How to File a Complaint

If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Privacy Officer

[PRIVACY OFFICER NAME] — Days of Our Lives
3331 East Livingston Avenue, Columbus, OH 43227
Phone: +1 (614) 805-6175
Email: daysofourlives1934@gmail.com

U.S. Department of Health and Human Services, Office for Civil Rights

200 Independence Avenue, S.W., Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints

Acknowledgement

We will ask you to sign a written acknowledgement that you have received this notice at the time of your first appointment.