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By clicking the "I AGREE" checkbox, you also indicate that you accept financial responsibility, if any, for the Ideal Option services you receive. We may verify your insurance benefits and may submit a claim to your health insurer for payment. Without waiving your financial responsibility, you agree to assign your right to medical benefits to Ideal Option. If your health insurer does not pay your claim, or only pays a portion of your claim, you agree to pay the remaining charges. I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered.
THIS NOTICE DESCRIBES HOW MEDICAL, DRUG, AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice is being provided to you as a requirement of two federal laws: the Health Insurance Portability and Accountability Act (HIPAA) 42 U.S.C. §1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 U.S.C. § 290dd-2, 42 CFR Part 2 (“Part 2”).
Under these laws, Ideal Option, PLLC (“Ideal Option”) may not say to a person outside Ideal Option that you are a patient in the clinic, nor may Ideal Option disclose any information identifying you as an alcohol or drug abuser, or disclose any other Protected Health Information (“PHI”) except as permitted by federal law. Your PHI means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.
This Notice describes how Ideal Option may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI in some cases.
Ideal Option must obtain your written consent before it can disclose information about you for payment purposes. For example, Ideal Option must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before Ideal Option can share information for treatment purposes or for healthcare operations. However, federal law permits Ideal Option to disclose information without your written permission for the following:
Before Ideal Option can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. You may revoke any such written consent in writing, except to the extent that Ideal Option has already acted on it.
If you are a minor, Ideal Option may disclose the fact that you have applied for treatment from Ideal Option to a parent/guardian/other authorized person if Ideal Option’s program director determines that you lack capacity because of extreme youth or mental or physical condition to make a rational decision whether to consent to disclosure to your parent, guardian or other authorized person and your situation poses a substantial threat to your life or physical well-being or that of any other person that may be reduced by communicating relevant facts to your parent or guardian.
You have the following rights regarding your health information:
A. The right to inspect and copy your protected health information.
You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as Ideal Option maintains the PHI. A “designated record set” contains medical and billing records and any other records that your physician and the facility uses for making decisions about you. If information in a “designated record set” is maintained electronically, you may request an electronic copy in a form and format of your choice that is readily producible or, if the form/format is not readily producible, you will be given a readable electronic copy.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law that prohibits access to PHI. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.
Ideal Option may deny your request to inspect or copy your PHI if, in its professional judgment, Ideal Option determines that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.
To inspect or copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Notice. If you request a copy of your information, Ideal Option may charge you a fee for the costs of copying, mailing or other costs incurred by Ideal Option in complying with your request.
Please contact Ideal Option’s Privacy Officer if you have questions about access to your medical record.
B. The right to request a restriction on uses and disclosures of your protected health information.
Under HIPAA, you may ask Ideal Option not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Ideal Option is not required to agree to a restriction that you may request, and Ideal Option will notify you if Ideal Option denies your request to a restriction. If Ideal Option does agree to the requested restriction, it may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, Ideal Option may terminate its agreement to a restriction. You may request a restriction by contacting the Privacy Officer.
C. The right to request to receive confidential communications from Ideal Option by alternative means or at an alternative location.
You have the right to request that Ideal Option communicate with you in certain ways. Ideal Option will accommodate reasonable requests. Ideal Option may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Ideal Option will not require you to provide an explanation for your request. Requests must be made in writing to the Privacy Officer.
D. The right to request amendments to your protected health information.
You may request an amendment of PHI about you in a designated record set for as long as Ideal Option maintains this information. In certain cases, Ideal Option may deny your request for an amendment. If Ideal Option denies your request for amendment you have the right to file a statement of disagreement with Ideal Option and Ideal Option may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to Ideal Option’s Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.
E. The right to receive an accounting.
You have the right to request an accounting of certain disclosures of your PHI made by Ideal Option. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. Ideal Option is also not required to account for disclosures that you requested, disclosures that you agreed to by signing a consent form, or certain other disclosures Ideal Option is permitted to make without your authorization. The request for an accounting must be made in writing to the Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years. Ideal Option will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
F. The right to obtain a paper copy of this notice.
Upon request, Ideal Option will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.
Ideal Option is required by law to maintain the privacy of your health information and report to you any breach of unsecured PHI. Ideal Option is also required to provide you with this Notice of Ideal Option’s duties and privacy practices and shall abide by terms of this Notice as may be amended from time to time. Ideal Option reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all future PHI that Ideal Option maintains.
You have the right to express complaints to Ideal Option and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to Ideal Option by contacting the facility’s Privacy Officer verbally or in writing, using the contact information below.
Ideal Option encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
Violation of Part 2 by a program such as Ideal Option is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.
Ideal Option’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer.
If you feel that your privacy rights have been violated by Ideal Option you may submit a complaint to the Privacy Officer by sending it to: Hannah Phenneger 5615 Dunbarton Ave. Pasco, WA 99301 ATTN: Privacy Officer
The Privacy Officer can be contacted by telephone at 877-522-1275.
This Notice is effective February 17, 2016.