THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Music Therapy Services of Central Wisconsin, LLC (the "Practice") is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information ("PHI"), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this "Notice"), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.
YOUR RIGHTS
Your rights regarding HIPAA are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below. Health Insurance Portability Accountability Act (HIPAA) Client Rights & Therapist Duties This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communication between a patient and a therapist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit my disclosure to what is necessary. Reasons we may have to release your information without authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them. If a patient files a complaint or lawsuit against Music Therapy Services of Central Wisconsin LLC, we may disclose relevant information regarding that patient in order to defend the group. If a patient files a worker's compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider. We may disclose the minimum necessary health information to immediate business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment If clinician knows, or has reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law required that the clinician file a report with the Wisconsin Abuse Hotline. Once such a report is filed, the clinician may be required to provide additional information. If the clinician knows or has reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires a report to be filed with the Wisconsin Abuse Hotline. Once such a report is filed, the clinician may be required to provide additional information. If the clinician believes that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, the clinician may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
CLIENT RIGHTS AND THERAPIST DUTIES
Use and Disclosure of Protected Health Information: For Treatment – we use and disclose your health information internally in the course of your treatment. If the clinician chooses to provide information outside of our practice for your treatment by another health care provider, you will sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
For Payment – Music Therapy Services of Central Wisconsin may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
For Operations – Music Therapy Services of Central Wisconsin may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.
Patient's Rights: Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your clinician is not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.50 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If your request is refused, you have a right of review, which the clinician will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and your clinician will decide if it is and if refused, your clinician will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, our billing department will discuss with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information Music Therapy Services of Central Wisconsin will make sure the person has this authority and can act for you before your clinician takes any action.
Right to Choose – You have the right to decide not to receive services with me. If you wish, your clinician will provide you with names of other qualified professionals.
Right to Terminate – You have the right to terminate therapeutic services wit your clinician at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with your clinician in session before terminating or at least contact your clinician by phone or email letting them know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not releasing the information in question to that person or agency might be harmful to you. Therapist's Duties: Clinicians are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. Music Therapy Services of Central Wisconsin reserves the right to change the privacy policies and practices described in this notice. Unless Music Therapy Services of Central Wisconsin notifies you of such changes, however, Music Therapy Services of Central Wisconsin is required to abide by the terms currently in effect. If these policies and procedures are revised, you will be provided with a revised notice in your client portal. COMPLAINTS If you are concerned that your privacy rights have been violated or you disagree with a decision made about access to your records, you may contact Music Therapy Services of Central Wisconsin, the State of Wisconsin Department of Health, or the Secretary of the U.S. Department of Health and Human Services.
BY SUBMITTING MY INFORMATION I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. This Notice is effective October 1, 2024