CHARLETTE MIKULKA, LCSW, LLC
973-726-6700 charlettem@pm.me
NOTICE OF PRIVACY PRACTICES
Effective April 30, 2020
Your Information. Your Rights. My Responsibilities.
This notice describes how health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
You have the right to:
- Get a copy of your paper or electronic health record
- Correct your paper or electronic health record
- Request confidential communication
- Ask me to limit the information I share
- Get a list of those with whom I’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that I use and share health information as I:
- Provide mental health care
My Uses and Disclosures
I may use and share your health information as I:
- Treat you
- Run my organization
- Help with public health and safety issues
- Comply with the law
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.
Get an electronic or paper copy of your health record
- You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you.
- I will provide a copy or a summary of your health information, usually within 30 days of your request.
Ask me to correct your health record
- You can ask me to correct health information about you that you think is incorrect or incomplete.
- I may say “no” to your request, but I’ll tell you why in writing within 30 days.
Request confidential communications
- You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- I will say “yes” to all reasonable requests.
Ask me to limit what I use or share
- You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get a list of those with whom I’ve shared health information
- You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.
- I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- I will make sure the person has this authority and can act for you before I take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel I have violated your rights by contacting me using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- I will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and I will follow your instructions.
In these cases, you have both the right and choice to tell me to:
- Share information with your family, close friends, or others involved in your care.
- Share information in a disaster relief situation.
If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your health information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases I never share your health information unless you give me written permission:
- Marketing purposes- I never market using clients’ personal information
- Sale of your information- I never sell clients’ personal information
- Most sharing of psychotherapy notes- I always keep progress notes and on occasion keep separate psychotherapy notes for extra sensitive client information
- Fundraising- I never engage in fundraising for my psychotherapy practice
My Uses and Disclosures
How do I typically use or share your health information?
I typically use or share your health information in the following ways.
Treat you
I can use your health information and share it with other professionals who are treating you only with your signed consent.
Example: I may find it beneficial to your overall treatment to collaborate with your psychiatric nurse practitioner, psychiatrist or physician who prescribes medication for your mental health condition.
Run my organization
I can use and share your health information to run my practice, improve your care, and contact you when necessary. I use health information about you to manage your treatment and services.
Example: In order to provide you with better service, I may share your health information when engaging in case consultation with another therapist. I will not, however, disclose any identifying information.
Example: In the event that I am incapacitated, I have designated a colleague who will contact you about my circumstances and arrange continuity of therapy.
I do not bill for your services
I do not use and share your health information to bill and get payment from health plans or other entities. I will always give you a receipt for services which you will use to submit claims.
Example: I do not contact your health insurance plan so it will pay for your services.That is strictly between you and your insurance plan.
How else can I use or share your health information?
I am allowed or required to share your information in other ways – usually in ways that contribute to the public good.
Help with public health and safety issues
I can share health information about you for certain situations such as:
- Reporting suspected child abuse or neglect, as well as domestic abuse, neglect or exploitation of vulnerable, dependent adults
- Preventing or reducing a serious threat to anyone’s health or safety
I will endeavor to discuss the matter with you prior to making a report, if possible, but I don’t require your verbal or written consent to take action. If you communicate to me a threat of imminent serious physical violence against a readily identifiable victim or yourself and I believe you intend to carry out that threat, I must take steps to warn and protect. I must also take such steps if there is a belief that you intend to carry out such violence, even if you have not made a specific verbal threat. The steps I take to warn and protect may include arranging for you to be evaluated for admission to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18 and warning your parents if you are under 18.
Do research
If I participate in any health related research, I will not share any identifying information, such as name, birthdate, contact information or social security number .
Comply with the law
- I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see whether I am complying with federal privacy law.
- For law enforcement purposes, including reporting crimes occurring on my premises, I may disclose your health information.
Address workers’ compensation, law enforcement, and other government requests
In the following cases where disclosure is permitted or required by law, I will seek your written consent, although I am able to release without it.
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official, including reporting crimes occurring on my premises
- With health oversight agencies for activities authorized by law which conduct audits, investigations, civil or criminal proceedings
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- I can share health information about you in response to a court or administrative order, or in response to a subpoena. In the case of subpoenas, I will seek legal efforts to have the subpoena quashed. I also will seek your written authorization before releasing the information. I will seek to provide a summary that reflects the essential information in your records, without divulging specific details that are sensitive and unnecessary to the legal process.
- I will aim to protect the confidentiality of clients during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders social workers to disclose confidential or privileged information without a client's consent and such disclosure could cause harm to the client, as a social worker I will request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection.
Other Uses and Disclosures
- Appointment reminders and health related benefits or services- I may use and disclose your personal health information to contact you to remind you of an appointment with me. I may also use and disclose your health information to tell you about treatment alternatives or other health care services or benefits that I offer.
I am permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent, though I will always seek your written authorization first:
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
My Responsibilities
- I am required by law to maintain the privacy and security of your protected health information.
- I will follow my Social Work Code of Ethics, which in a number ways provides greater confidentiality than Health Insurance Portability and Accountability Act (HIPAA) standards.
- In line with my Social Work Code of Ethics, I will disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made will be revealed.
- I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- I must follow the duties and privacy practices described in this notice and give you a copy of it.
- I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
Changes to the Terms of this Notice
I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office, and on my web site.
Privacy Official
I am the Privacy Official for this health care practice. My contact information is at the top of the first page.
By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices, read it and understood it.