THIS INFORMATION DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and
your health. This information about you that may identify you
and that relates to your past, present or future physical or
mental health or condition and related health care services is
referred to as Protected Health Information (“PHI”). This Notice
of Privacy Practices describes how we may use and disclose your
PHI in accordance with applicable law and the NASW Code of
Ethics. 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 notice of our legal duties and privacy
practices with respect to PHI. We are required to abide by the
terms of 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 sending a
copy to you in the mail upon request or providing one to you at
your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used by those who are involved in
your care for the purpose of providing, coordinating, or
managing your health care treatment and related services. This
includes consultation with clinical supervisors or other
treatment team members. We may disclose PHI to any other
consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive
payment for the treatment services provided to you. This will
only be done with your authorization. If it becomes necessary to
use collection processes due to lack of payment for services, we
will only disclose the minimum amount of PHI necessary for
purposes of collection.
For Health Care Operations. We may use or disclose, as needed,
your PHI in order to support our business activities including,
but not limited to, quality assessment activities, employee
review activities, licensing, and conducting or arranging for
other business activities. For example, we may share your PHI
with third parties that perform various business activities
(e.g., billing or typing) provided we have a written contract
with the business that requires it to safeguard the privacy of
Required by Law. Under the law, we must make disclosures of 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.
Without Authorization. Applicable law and ethical standards
permit us to disclose information about you without your
authorization only in a limited number of other situations. The
types of uses and disclosures that may be made without your
authorization are those that are:
■ Required by Law, such as the mandatory reporting of child
abuse or neglect or mandatory government agency audits or
investigations (such as the social work licensing board or the
■ Required by Court Order
■ Necessary to prevent or lessen a serious and imminent threat
to the health or safety of a person or the public. 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
Verbal Permission. We may use or disclose your information to
family members that are directly involved in your treatment with
your verbal permission.
With Authorization. Uses and disclosures not specifically
permitted by applicable law will be made only with your written
authorization, which may be revoked.
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 our Privacy Officer, Patty Masterson-Kane, LCSW,
at 653 Shawnee Drive, Franklin Lakes, and NJ 07417.
■ Rights of access to Inspect and Copy. You have the right,
which may be restricted only in exceptional circumstances, to
inspect and copy PHI that may be 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. We may charge a
reasonable, cost-based fee for copies.
■ Right to Amend. If you feel the PHI we have about you is
incorrect or incomplete, you may ask us to amend the information
although we are not required to agree to the amendment.
■ Right to Accounting of Disclosures. You have a right to
request an accounting of certain of the disclosures we make of
your PHI. We may charge a reasonable fee if you request more
than one accounting in any 12-month period.
■ Right to Request Restrictions. You have the right to request a
restriction or limitation on the use or disclosure of your PHI
for treatment, payment, or health care operations. We are not
required to agree to your request.
■ Right to request Confidential Communication. You have the
right to request that we communicate with you about medical
matters in a certain way or at a certain location.
Right to a copy of this Notice. You have a right to a copy of
If you believe we have violated your privacy rights, you have a
right to file a complaint in writing with our Privacy Officer,
Patty Masterson- Kane, LCSW, 653 Shawnee Drive, Franklin Lakes,
NJ 07417, or with the Secretary of Health and Human Services at
200 Independence Avenue, S.W. Washington, D.C. 20201 or by
calling (202) 619-0257. We will not retaliate against you for
filing a complaint.