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The following is the Notice of Privacy Practices of Selfless Esteem, Inc. (CA), Selfless Esteem, PLLC (TX), and Selfless Esteem, LLC (LA). HIPAA is a Federal law that requires us to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy policies with respect to your protected health information. We are required by law to abide by the terms of this Notice of Privacy Practices.
Your Protected Health Information:
Your "protected health information" (PHI) broadly includes any health information, oral, written or recorded, that is created or received by us, other healthcare providers, and health insurance companies or plans, that contains data, such as your name, address, social security number, and other information, that could be used to identify you as the individual patient who is associated with that health information. This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with the notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms on this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy to our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
We use a patient portal through My Best Practices electronic record system, which is HIPAA compliant and PCI compliant with multiple layers of encryption to protect data and secure data servers monitored 24/7. The staff of My Best Practice (e.g., Information Technology staff) may have access to records to accomplish the purpose of providing the electronic record system; however, as stated they abide by HIPAA confidentiality laws. You have the option to opt-out from PHI being disclosed by these services. Please see My Best Practice’s privacy policy for more information at www.mbpractice.com/privacy-policy.
Uses or Disclosures of your Protected Health Information:
Generally we may not "use" or "disclose" your PHI without your permission, and must use or disclose your PHI in accordance with the terms of your permission. "Use" refers generally to activities within our office. "Disclosure" refers generally to activities involving parties outside of our office. The following are the circumstances under which we are permitted or required to use or disclose your PHI. In all cases, we are required to limit such uses or disclosures to the minimal amount of PHI that is reasonably required.
Without Your Written Authorization:
The following categories describe different ways that we use your health information and disclose your health information to third parties. We have not listed every use or disclosure within the categories below. For more information on how we can use your protected health information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Without your written authorization, we may use within our office, or disclose to those outside our office, your PHI in order to provide you with the treatment you require or request, to collect payment for our services, and to conduct other related health care operations as follows:
Treatment activities include: (a) to provide treatment and other services to you, e.g., diagnose and treat your behavioral issues (b) to provide appointment reminders, information about treatment alternatives or other health-related benefits and services that may be of interest to you and (c) to disclose PHI to other providers involved in your treatment when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
Payment activities include: (a) disclosures for billing for which we may utilize the services of outside billing companies and claims processing companies with which we have Business Associate Agreements that protect the privacy of your PHI; and (b) disclosures to attorneys, courts, collection agencies and consumer reporting agencies, of information as necessary for the collection of our unpaid fees, provided that we notify you in writing prior to our making collection efforts that require disclosure of your PHI.
Health care operations may include disclosures to our attorney, accountant, bookkeeper and similar consultants and contractors to our healthcare operations, provided that we have entered into Business Associate Agreements with such consultants for the protection of your PHI.
Disclosure to Individuals involved in your care or payment for your care:
We may share health information with your family, close friends, or others involved in your care or payment for your care.
Required by Law:
Under the law we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Please note that unless you request otherwise, and we agree to your request, we will use or disclose your personal health information for payment activities and healthcare operations as specified above without written authorization from you.
Without Authorization:
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. Examples of instances in which we are required to disclose your PHI include: (a) disclosures regarding reports of child, elder, and dependent adult abuse or neglect, domestic violence including reporting to social service or child protective services agencies; (b) health oversight activities including audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions, or other activities necessary for appropriate oversight of government benefit programs; (c) judicial and administrative proceedings in response to an order of a court or administrative tribunal or other lawful process; (d) regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA; (e) in a medical emergency situation to medical personnel only in order to prevent serious harm; (f) close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm; (g) to the extent necessary to protect you, another person or the public from a serious imminent risk of danger presented by you. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat; (h) a law enforcement official as required by law, in compliance with subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises; (i) specialized government functions in that we may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm; (j) mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and to notify emergency response employees regarding possible exposure to a disease or who may be at risk for contracting or spreading a disease or condition. (k) information may be disclosed to family members that are directly involved in your treatment with your verbal permission; (l) for workers compensation claims, and (m) as required by the secretary of health and human services to investigate or determine our compliance with federal regulations, including those regarding government programs providing public benefits; (n) we may disclose your PHI to a coroner, medical examiner, or funeral director as authorized by law. This may be necessary, for example, to identify a deceased person or determine the cause of death. Only the minimum medical information required to achieve the intended purpose will be used or disclosed to third parties. You cannot opt-out from mandated disclosures.
All Other Situations With Your Specific Written Authorization:
Except as otherwise permitted or required as described above we may not use or disclose your PHI without your written authorization. Further we are required to use or disclose your PHI consistent with the terms of your authorization. If you authorize us to use or disclose health information about you, you may revoke that authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons stated in your written authorization. Please understand that we are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care we provide to you.
The following uses and disclosures will be made only with your written authorization: (i) Most uses and disclosures of psychotherapy notes. "Psychotherapy notes" are defined as records of communications during individual or family counseling which may be maintained in addition to and separate from medical or healthcare records; (ii) Most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; Exceptions include direct face-to face communication or if the marketing activity is to provide you with information about our treatment options or services. (iii) disclosures that constitute a sale of PHI; (iv) disclosures of drug and alcohol abuse treatment, (v) Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) test results and (vi) other uses and disclosures not described in the Notice of Privacy Practices.
Your Rights Regarding Your PHI:
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to the address listed above or through secure messaging in the client portal at My Best Practice.
Right to Access to Inspect and Copy:
You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains mental health billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. Clients have the right to access the records. Please request in writing a Records Request form to the address above or in the My Best Practice client portal. Complete and submit it to Gina Leggio, LMFT, at the address above or in the My Best Practice client portal. Either a summary can be provided or a copy. When requesting a copy, please allow 15 days to provide a copy. When requesting a summary, please allow 10 days from the request date unless the record is quite extensive, in which case please allow up to 30 days for a summary. If your records are maintained electronically, you may also request an electronic copy of your PHI.
You may request that a copy of your PHI be provided to another person. You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s PHI will not be accessible to you (for example, records pertaining to health care services for which the minor can lawfully give consent and therefore for which the minor has the right to inspect or obtain copies of the record); or the health care provider determines, in good faith, that access to the client records requested by the representative would have a detrimental effect on the provider’s professional relationship with the minor client or on the minor's physical safety or psychological well-being.
Right To Amend Your Protected Health Information:
You have the right to request that we amend your PHI for as long as your medical record is maintained by us. We have the right to deny your request for amendment. We require that you submit a written request and provide a reason to support the requested amendment. Please request a Amendment/Addendum Request Form from Gina Leggio, LMFT, through the client portal or at the address above. If we deny your request, we will provide you with a written denial within 60 days stating the basis of the denial and note your right to submit a written statement disagreeing with the denial, and a description of how you may file a complaint with us and/or the Secretary of the U.S. Department of Health and Human Services (DHHS). If we accept your request for amendment, we will make reasonable efforts to provide the amendment within a reasonable time to persons identified by you as having received PHI of yours prior to amendment and persons that we know have the PHI that is the subject of the amendment and that may have relied, or could foreseeably rely, on such information to your detriment.
Right To Receive an Accounting of Disclosures of Your Protected Health Information:
You have the right to receive a written accounting of all disclosures of your PHI for which you have not provided an authorization that we have made within a six (6) year period immediately preceding the date on which the accounting is requested. You may request an accounting of such disclosures for a period of time less than six (6) years from the date of the request. We require that you request it in writing by completing and submitting an Accounting of Disclosures Request Form. To obtain the form, please contact Gina Leggio, LMFT, at the address or phone number above. The accounting of disclosures will include the date of each disclosure, the name of the person who received the information, their title and agency, a brief description of the information disclosed, and a brief statement of the purpose and basis of the disclosure or instead of such statement, a copy of your written authorization or written request for disclosure pertaining to such information. We are not required to provide accountings of disclosures for the following purposes: (a) payment and healthcare operations, (b) disclosures pursuant to your authorization, (c) disclosures to you, (d) to other health care providers involved in your care, (e) for national security or intelligence purposes, and (f) to correctional institutions. We reserve the right to temporarily suspend your right to receive an accounting of disclosures to health oversight agencies or law enforcement officials, as required by law. We will provide the first accounting to you in any twelve (12) month period without charge but will impose a reasonable cost-based fee for responding to each subsequent request for accounting within that same twelve (12) month period.
Right to Request Restrictions:
You have the right to request a restriction or limitation on the use of disclosure of your PHI for payment or health care operations. While we will consider all requests for additional restrictions carefully, we are not required to agree to your request. Please obtain a request form from Gina Leggio, LMFT, at the address above or through the client portal.
Right to Request Confidential Communication:
You have the right to request that we communicate with you about health matters in a certain way or at a certain location, e.g., home phone or office phone. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request. You must make your request in writing.
Sharing Information:
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us 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 us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
We never market or sell personal information. We will never share any substance abuse treatment records without your written permission. We will not contact you or your parent/guardian to request a tax-deductible contribution.
Breach Notification:
If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
Right to Copy of This Notice:
You have the right to a copy of this notice. You may obtain a copy of this notice at our website: https://selfless-esteem.com. Even if you have agreed to receive such notice electronically, you are still entitled to a paper copy of this notice. Please contact Gina Leggio, LMFT, through the address above or through the client portal to request a paper copy.
Complaints:
You may file a complaint with us and with the Secretary of DHHS if you believe that your privacy rights have been violated. Please submit any complaint to us in writing by mail to Gina Leggio, LMFT, at the mailing address above. A complaint must name the subject of the complaint and describe the acts or omissions believed to be in violation of the applicable requirements of HIPAA or this Notice of Privacy Practices. 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/. You will not be retaliated against for filing any complaint.
Amendments to this Notice of Privacy Practices:
We reserve the right to revise or amend this Notice of Privacy Practices at any time. These revisions or amendments may be made effective for all PHI we maintain even if created or received prior to the effective date of the revision or amendment. Upon your written request, we will provide you with the notice of any revisions or amendments to this Notice of Privacy Practices or changes in the law affecting this Notice of Privacy Practices by mail or electronically within 60 days of receipt or your request.
We will provide you with a copy of the most recent version of this Notice of Privacy Practices at any time upon your written request sent to Gina Leggio, LMFT, at the address above. For any other requests or for questions pertaining to the privacy of your PHI, and for information regarding the filing of a complaint, please contact us at the address or telephone number listed above.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.