WHAT IS A NOTICE OF PRIVACY PRACTICES?
A Notice of Privacy Practices is a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how we can use your private health information, how it can be shared, the safeguards we have in place to protect the information, your rights of access, and the requirements we have to follow as a provider of health care.

ACKNOWLEDGEMENT OF THE RECEIPT OF THIS NOTICE
You will be given a Notice when you come to Expressive Therapy Center of Montgomery County. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. We will ask you to initial a spot on the Consent for Services and Treatment form that shows we gave you this information. The delivery of health care services is not conditioned on your signed acknowledgment of receiving this notice.

WHO WILL FOLLOW THIS NOTICE OF PRIVACY PRACTICES?
Expressive Therapy Center of Montgomery County (ETC), including all corporate entities and off-site locations, its employees, contractors, and volunteers will comply with the protections of privacy as described in this notice.

WHAT IS PROTECTED HEALTH INFORMATION AND WHAT ARE OUR DUTIES TO YOU?
Protected Health Information is individually identifiable health information. This information includes demographics (such as name, address, age or phone number) and medical care information (such as name of illness, health services we provide or medications). Past, present and future information is protected.
We are required by HIPAA to do the following:

• Make sure private information is kept private.
• Give you this Notice that explains how we use your information
• Do what we say in this Notice
• Tell you about any changes we make to the information in this Notice.

We reserve the right to change or revise this Notice. This Notice and any changes apply both to information we have already collected about you and information we may collect in the future. You can ask for a Notice of our Privacy Practices any time. Our Notice is also posted at our main location.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following are examples of the permitted uses and disclosures of your protected health information. These are examples and not intended to be exhaustive.

REQUIRED USES AND DISCLOSURES
By law we must disclose your information to you unless a medical authority determines that access to that information may be harmful to you. We must also disclose information to the Secretary of the Department of Health and Human Services for investigations or determination, or our compliance with laws about privacy.

• TREATMENT: We will use and disclose your information to provide, coordinate or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your information to their primary care physician, a specialist involved with the care, a laboratory, or others providing assistance with the health care diagnosis or treatment. In emergencies we will use and disclose the information to provide the treatment you require.
• PAYMENT: The information will be used as needed to obtain payment for health care services. This might include determining eligibility, obtaining referrals or approval for your admission.
• RESEARCH: We may disclose your protected health information to researchers when allowed by law, for example, if their research has been approved by an Institutional Review Board that has reviewed the research proposal and established a plan to ensure the privacy of your protected health information. We may disclose your protected health information to researchers preparing and planning a research project, for example to help look for patients who may have specific medical conditions, so long as the information does not leave the hospital.
• PARENTAL ACCESS: Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians and persons acting in a similar capacity or legal status, such as a patient representative. We will act consistently with state laws where the treatment is provided and will make disclosures following such laws whenever the state law is more protective of privacy than the Federal law. We will make every effort to protect children's rights to a private physician/patient relationship.

WHEN WILL YOUR PERMISSION FOR USES OF YOUR INFORMATION BE REQUIRED?
In some circumstances you have the opportunity to agree or object to the use or disclosure of all or part of your information.

• MARKETING AND FUND RAISING ACTIVITIES We may use medical information about you to contact you in an effort to raise money. We only would release contact information such as your name, address and phone number and the dates you received treatment or services by ETC.
• INDIVIDUALS INVOLVED IN YOUR CARE We will always make every effort to get permission from you to disclose information about your care. We will make every effort to help you be the agent for information about you. When you are not available, this may mean that you will need to identify the names of any alternate representative(s) that are authorized to receive patient information. Except in cases where ETC has been presented with a court document restricting or redirecting parental rights, you are aware that either parent may see the medical record, visit the patient, take the child home, or make care decisions. We may need to disclose information to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals.

WHAT ARE YOUR PATIENT RIGHTS?
We will protect the privacy rights of patients. We have rules in place so that patients and families, parents, guardians, and others can do things explained in these rights. Your Rights include:

1. The right to a copy of this Notice of Privacy Practices.
2. The right to reasonable requests that health information not be used or disclosed for treatment, payment, or health care operations (except for those required by law).
3. The right to change your mind and take back an authorization for use or disclosure of protected health information, when it is reasonable.
4. The right to request to be contacted or called to get communications by various means (by phone, e-mail, fax, or standard mail) or at an alternative location.
5. The right to be given a place and time to look at, read, inspect, add to, or copy your health information.
6. The right to request a report of each time your health information has been shared with anyone other than for uses related to treatment, payment or health care operations as described in this Notice.

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your permission. If you provide authorization to use and disclose information about you, you have the right to revoke the permission in writing at any time. If you revoke your permission, we will no longer disclose the information for the reasons covered in your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

HOW DO I FILE A COMPLAINT?
Any patient, parent or legal guardian or patient representative may file a verbal or written formal complaint. Call the Family Services Department of ETC at (30 I) 869-1017, ext.5 for assistance. The Family Services Department is responsible for ensuring that the complaining party receives a written response within 45 days. Responses will include the steps we are taking to investigate the complaint and the results of the investigation, the date of completion and a contact person and phone number.
You may also file a complaint with the U.S. Office of Civil Rights, or the Department of Health and Human Services. In any case, no retaliation will be made against you for filing such a complaint.

HEALTH CARE OPERATIONS We may use your information to support improvement in our daily activities related to health care operations, such as quality planning and improvement, staff performance reviews, completing licensing requirements, and other normal processes needed in health care. We will disclose your information, when needed, to schedule an appointment, remind you of appointments, call your name in the waiting areas, and have you sign in when you arrive. We may share your information with third party business associates who perform various activities for us and who promise to protect our information in the same manner as we protect it. We may also use your information to provide alternative options for care. For example, we may ask if you wish to receive a newsletter that helps other families with your diagnosis. We may send you information about products or services that might benefit you and your family.

REQUIRED BY LAW
We may use or disclose information if law or regulation requires it. For example, ETC will comply with regulations that require reporting certain medical outcomes to government agencies.

PUBLIC HEALTH. We may disclose your protected health information to a public health authority who is permitted by law to collect or receive the information. This disclosure may be necessary to:

• Prevent or control disease, injury or disability.
• Report deaths.
• Report child abuse or neglect.
• Report reactions to medications or problems with products.
• Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or violence.

COMMUNICABLE DISEASES
We may disclose your protected health information, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition

HEALTH OVERSIGHT
We may find it necessary to disclose your health information to an oversight agency for activities such as audits, investigations or inspections. These health oversight agencies may include the government that oversees the health care system, voluntary inspections or credentialing organizations and other licensed groups.

FOOD AND DRUG ADMINISTRATION. We may find it necessary to disclose your health information to a person or company required by the Food and Drug Administration to:

• Report adverse events.
• Track products.
• Enable product recalls.
• Make repairs or replacements.

LEGAL PROCEEDINGS. We may find it necessary to disclose health information during any judicial or administrative proceedings in response to a court order, warrant, subpoena, discovery request or other lawful process.

LAW ENFORCEMENT. We may find it necessary to disclose health information for law enforcement purposes such as:

• Response to legal proceedings
• Information requests for identification or location
• Circumstances pertaining to victims of a crime
• Deaths or medical emergencies suspected to have resulted from criminal conduct
• If it is necessary to identify or apprehend an individual

CRIMINAL ACTIVITY. We may find it necessary to disclose your health information if we believe that its use and disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

SPECIAL SITUATIONS. We may find it necessary to disclose your health information to coroners, funeral directors or medical examiners for their performance of duties as authorized by law. Protected health information may be used and disclosed to organizations that handle the procurement for cadaveric organ, eye or tissue donation or transplant