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138 W25th St, Suite 605 New York, NY 10001 www.artspringnyc.

com

THIS NOTICE DESCRIBES H OW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND H OW YOU CAN G ET ACCESS T O T HIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Medical privacy regulations issued by the U.S. Department of Health and Human Services under the Health Insurance Portability and A ccountability Act of 1996 (HIPAA) become effective April 14, 2003. We are required by law to maintain the privacy of your mental health information and to provide you with this notice of our legal duties and privacy practices with respect to your mental health information. This notice is designed to inform y ou about ArtSpring C reative Arts Therapy, PLLCs Privacy Practices. We are required by law to give y ou this notice. This notice will describe how we may use and disclose information that is called "protected health information" (PHI). PHI is a ny i nformation, whether it is oral, recorded, or demographic data that may i dentify y ou (i.e., name, address, diagnosis) or that may relate to your past, present or future mental health. We will also outline y our rights and our obligations regarding the use and disclosure of that information. This notice describes your rights regarding health information we maintain about you a nd a brief description of how you may exercise these rights. This notice further states the obligations we have to protect y our mental health information. Uses and Disclosures of your Mental Health Information Without your Permission: We will use and disclose y our mental health information f or treatment, payment and operations purposes within our Institute, with appropriate staff members only, without a ny a uthorization from y ou. Treatment includes: direct provision of mental health services consultation (e.g. with treatment team, psychiatrist) transfer between therapists Payment includes: obtaining eligibility verification, pre-authorization, ongoing authorization billing claims collection Health Care Operations include: matters related to q uality improvement utilization review general administration business planning and management legal and a uditing services site visits pertaining to licensing and a ccreditation In all of the above situations, we will make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure or request. We may also use and disclose y our mental health information without y our a uthorization or opportunity to object in the following situations: 1. Emergencies: We may use and disclose y our information in emergency treatment situations (for example, admission to hospital, ambulance).

Notice of Privacy Practices

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As required by law: We will use and disclose y our information when we are required to do s o by federal, s tate or local law. To avert a serious threat to health or safety: We may use and disclose your information when necessary to prevent a serious and imminent threat to your health a nd safety or to the health and safety of the public or a nother person. Under these circumstances we will only disclose health i nformation to s omeone who is a ble to help prevent or lessen the threat. Public health a ctivities: We may disclose mental health i nformation a bout y ou as necessary for public health activities including disclosures to: a. report to public health a uthorities for the purpose of preventing or controlling disease, injury or disability; b. report vital events s uch as deaths, as required by N YS law; c. report child abuse or neglect; d. report to the Food a nd Drug A dministration (FDA) information about defective products or problems with medications; e. notify a person who may have been exposed to a communicable disease or who is at risk of contracting or spreading a disease or condition.

We may disclose mental health information about you to a health oversight agency f or activities authorized by l aw. These include government agencies that oversee the mental health care system, government benefit programs s uch as Medicaid, and other government programs regulating mental health care. We may disclose mental health information about you to a court or a dministrative agency when a judge orders us to do s o via a subpoena. We will make a reasonable effort to notify you to obtain your a uthorization. In all of the above, disclosure will be limited t o information necessary t o carry out the purpose of the disclosure. Uses and Disclosures of your Mental Health Information with your Permission: Except f or the a bove-outlined areas, ArtSpring Creative Arts Therapy would request your written a uthorization to release y our mental health information. A t any time during y our treatment, y ou may revoke your a uthorization i n writing. If you revoke your a uthorization, we will not make any further uses or disclosures of your mental health information under that authorization. Your Rights Regarding your Mental Health Information: Right to inspect and copy: You have the right to request an opportunity to inspect or copy mental health information used to make decisions a bout y our care. You must s ubmit y our request in writing to ArtSpring Creative Arts Therapy at 138 W25th St, Suite 605, New York, NY 10001. We may deny your request to inspect or copy y our mental health information in certain limited circumstances. If y ou are denied access, y ou may request that the denial be reviewed. Right to make changes: If you believe that ArtSpring Creative Arts Therapy has mental health information about y ou that is incorrect or incomplete, you may ask us to make changes to correct the information. We ask that you submit this in writing and provide as m uch detail as possible as to what information needs to be changed and why. We may deny your request if you ask us to amend information that ArtSpring did not create, or if ArtSpring Creative Arts Therapy believes the information is complete a nd accurate. Right to Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we made of medical information about y ou f or purposes other than treatment, payment a nd health care operations. Please include time frames, which may not be longer than six years a nd may not include dates before April 14, 2003. ArtSpring Creative Arts Therapy will review all requests individually and comply with your request within 60 days, unless circumstances require a dditional time. We may charge a nominal fee f or this list if a request is made m ore than one time annually. Complaints: If y ou believe your privacy rights have been violated, y ou may file a complaint with us, or with the U.S. Department of Health a nd Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, NY 10278. You will not be penalized f or filing a complaint. To file a complaint with us, please do so i n writing to ArtSpring Creative Arts Therapy PLLC at 138 W25th St, Suite 605, New York, N Y 10001 CHANGES TO THIS NOTICE: We reserve the right to change the terms of our N otice of Privacy Practices. You may obtain a copy of our current N otice of Privacy Practice at our website, www.artspringnyc.com, or by requesting that a copy be sent to you in the mail.