Notice of Privacy Policy

Notice of Privacy Practice

THIS NOTICE DESCRIBES HOW PROTECTED PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

As part of providing services to you, we will collect information about your care. We need this information to provide you with quality services and to comply with certain legal requirements. This notice applies to all of the records of your care generated at NH Kelly (Neidy Hernandez Kelly). We are required by law to: ensure that information that identifies you is kept private; provide you with this notice of our legal duties and privacy practices with respect to information about you; and follow the terms of the notice that is currently in effect. NH Kelly (Neidy Hernandez Kelly) at (904) 442-6101 The terms of this notice apply to all records containing your identifiable health information that are created or retained by NH Kelly (Neidy Hernandez Kelly). We reserve the right to revise and amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records. NH Kelly (Neidy Hernandez Kelly) has created or maintained in the past and for any of your records that we may create or maintain in the future. We will post a copy of our current notice in each of our facilities in a prominent location. You may request a copy of our most current notice during any visit or by phone. The effective date of our notice will be posted in the upper left-hand corner of the notice.

WHO WILL FOLLOW THIS NOTICE

This notice describes the privacy practices of the entities that are part of New Hope Kinetics LLC including: Any professional authorized to enter information into your medical records; Any member of a volunteer group that assists you while you receive services from NH Kelly (Neidy Hernandez Kelly) and all employees, staff and other personel of NH Kelly (Neidy Hernandez Kelly). Please realize that other personnel of NH Kelly (Neidy Hernandez Kelly) may use different notices or policies regarding health information created in their offices.

HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU ARE AS FOLLOWED:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) The following categories describe different ways that we use and disclose information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories listed below. For Your Care and Services. We may use health information about you to provide, coordinate or manage the services, supports, and healthcare you receive from us and other providers. We may disclose health information about you to your medical care providers, your funding agency case manager, NH Kelly (Neidy Hernandez Kelly), other agency staff, or other persons who are involved in supporting you or providing care. For example, your direct care staff may need to share information about your medications with your psychiatrist or with your case manager. For Payment. We may use and disclose information about you so that services may be billed to and payment may be collected from you, an insurance company or other entity providing funding for your care. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For example, we may need to provide the state Medicaid program with information about the services we provide so that we can be reimbursed for those services. For Health Care/Service Operations. We may use and disclose information about you to run our program and to make sure you receive quality services, or to decide if we should change or modify our services. For example, we may disclose health information about you to train our staff. We may also use information for accreditation or licensing activities. Release of Information to Family/Advocates. We may release your health information to an advocate or family member that is helping you pay for your care who assists in taking care of you. In addition, we may disclose health information about you to an entity that is assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have specific objections or instructions regarding these communications, you may discuss them with us by contacting your service coordinator. Research. We may use and disclose health information about you for research purposes in certain limited circumstances. All research projects are subject to a special approval process. Before we use or disclose health information for research, the project will have been approved through the research approval process. However, we may disclose health information about you to people preparing to conduct a research project, for example, to help them look for individuals with specific health needs, so long as the health information they review does not leave our premises. We will always ask for your specific permission if the researcher requests to have access to your name, address or other information that reveals who you are or who will be involved in your care. Your participation in research projects is voluntary. As Required By Law. We will disclose information about you when required to do so by federal, state or local law. For example, we may reveal information about you to the proper authorities to report suspected abuse or neglect. To Avert a Serious Threat to Health or Safety. We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or of another person. Any disclosure, however, would only be to someone able to help prevent the threat. Military and Veterans. If you are a member of the armed forces, we may release information about you as required by military command authorities. Workers' Compensation. We may release information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illnesses. Public Health Activities. We may disclose information about you for public health activities. These activities generally include: The prevention or control of disease, injury or disability; Reports of child abuse or neglect; Notification that a person may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; Notifications to the appropriate authorities if we believe that you have been the victim of abuse, neglect or domestic violence. Health Oversight Activities. We may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for appropriate oversight of the health care system, government programs and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, or if there is a lawsuit or dispute concerning your services, we may disclose information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. If asked to do so by a local, state or federal law enforcement official we may release health information: 1. In response to a court order, subpoena, warrant, summons or similar process; 2. To identify or locate a suspect, fugitive, material witness, or missing person; 3. About the victim of a crime in certain limited circumstances, if we are unable to obtain the person's agreement; 4. About a death we believe may be the result of criminal conduct; 5. About criminal conduct at any facility where you are receiving treatment; and 6. In emergency circumstances to report a crime (including the location or victim(s) of the crime, the description, identity or location of the perpetrator). Coroners, Medical Examiners and Funeral Directors. We may release information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release information to funeral directors as necessary to carry out their duties. National Security and Intelligence, Protective Services for the President and Others. We may release information about you to authorized Federal officials for intelligence, counterintelligence and other national security activities authorized by law. Correctional Programs. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official. This release would be necessary; for the institution to provide you with health care, to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING YOUR PROTECTED PERSONAL INFORMATION

You have the following rights regarding protected personal information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records. The right to inspect and copy health information does not include psychotherapy notes. To inspect and copy information that may be used to make decisions about you, you must submit your request in writing to your Lead therapist. If you need assistance, it will be provided to you. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Right to Amend. If you feel that the information we have about you is incorrect or incomplete, you may ask us to amend the information. You must make your request for an amendment in writing and submit it to your Lead therapist. In addition, you must provide a reason that supports your request. If you need assistance to put your request in writing, it will be provided to you. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: 1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; 2. Is not part of the information kept in your file; “Psychotherapy notes” means: notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. See 45 C.F.R. § 164.501. Please note, if material that otherwise meets the definition of psychotherapy notes is combined with (in other words, not kept separate from) the medical records, then those materials will not be subject to the special disclosure rules for psychotherapy notes under HIPAA. Is not part of the information, which you would be permitted to inspect and copy; or we believe is accurate and complete. If you disagree with the denial, you may submit a statement of disagreement. If you request an amendment to your record, we will include your request in the record whether the amendment is accepted or not. Right to an Accounting of Disclosures. We will keep a log record of disclosures made on or after January 2011, other than disclosures for treatment, billing, services or health care operations. You have the right to request an "accounting of disclosures". To request this list or accounting of disclosures, you must submit your request in writing to the Program Manager or State Director. If you need assistance, it will be provided to you. Your request must state a time period not longer than six years. Right to Request Restrictions. You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or a friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, we encourage you to make your request in writing to your Program Manager. If you need assistance, it will be provided to you. In your request, you must tell us: 1. What information you want to limit; 2. Whether you want to limit our use, disclosure, or both; and 3. To whom you want the limits to apply. Right to Request Confidential Communications. You have the right to request that we communicate with you about your services in a certain way or at a certain location. For example you can ask us to contact you only at work or only by mail. You must make your request to obtain confidential communications in writing to the Lead therapist. You must specify how or where you wish to be contacted. If you need assistance, it will be provided to you. We will not ask you the reason for your request. We will accommodate all reasonable requests. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, contact NH Kelly LLC.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for information we already have about you as well as any information we receive in the future. The effective date will appear on the lower left-hand corner of the first page. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with with NH Kelly (Neidy Hernandez Kelly) directly, every effort will be made to resolve any issues that arise. You may also file a complaint with the Secretary of the Department of Health and Human Services C/O Office for Civil Rights, US Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201. All complaints must be submitted in writing. If you need assistance, it will be provided to you. You will not be penalized or be retaliated against for filing a complaint. You may also contact the Joint Commission at 1-800-994-6610.

OTHER USES OF PROTECTED PERSONAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Consent for Communication

I consent to be communicated with via mail, email and/or phone. I will IMMEDIATELY advise NH Kelly LLC in the event of change. I give permission to allow referring person or agency to be thanked for referring me to NH Kelly (Neidy Hernandez Kelly), I further give permission to NH Kelly (Neidy Hernandez Kelly) to place my name on the NH Kelly (Neidy Hernandez Kelly) mailing list (not to be given or sold to any other individual or agency). I acknowledge that I have recieved and read the NH Kelly (Neidy Hernandez Kelly) Professional Disclosure Statement and Consent for Treatment and the HIPAA Client's Rights. I further acknowledge that I seek and consent to treatment. My signature below confirms that I understand and accept all the information contained in the NH Kelly (Neidy Hernandez Kelly) Professional Disclosure Statement and Consent for Treatment and the HIPAA Client's Rights.

Consent for Telemental Health Services This for is to be used as a supplement to the signed Service Agreement and Treatment Consent Form that is required for all clients receiving services from NH Kelly (Neidy Hernandez Kelly).

WHAT IS TELEMENTAL HEALTHCARE?

Telemental health is a subset of telehealth service that uses online, iteractive videoconferencing software to provide mental health services from a distance. Telemental health includes terms such as telepsychology, tele behavioral health, online counseling and distance counseling. private insurance companies in South Caroline and many other states are required by law to cover telemental health services. Telehealth does not include the use of fax, audio only (telephone), email or videotelephony products such as FaceTime and Skype.

WHAT ARE THE POTENTIAL RISKS OF TELEMENTAL HEALTH?

Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection. nonverbal cues might be more difficult to observe and interpret during therapist and client interactions. may electronically share and sign practice and consent forms and accept risks that come with transmitting information and documents over the internet.

WHAT ARE THE BENEFITS OF TELEMENTAL HEALTH?

less limited by geographical location and transportation concerns. decreases in travel time and ability to meet virtually during inclement weather conditions. ability to participate in treatment from your own home or other environment where you feel safe, secure and comfortable. ability to participate in treatment from your home or other environment when physical needs/disabilities may prevent you from coming to the office.

ELIGIBILITY

NH Kelly (Neidy Hernandez Kelly) is only able to provide telemental health services to clients located in South Carolina where we hold valid licenses as mental health professionals. Clients must provide a valid ID or other proof of residency before telemental health treatment sessions can begin. A copy of this proof of residency will be kept in a client's electronic file. Telemental health may not be the most effective form of treatment for certain individuals or presenting problems. If it is believed the client would benefit from another form of services (e.g. face-to-face sessions) or another provider, an appropriate recommendation will be made.

PRIVACY AND CONFIDENTIALITY

The current laws that protect privacy and confidentiality also appy to telemental health services. Exceptions to confidentiality are described in the Notice of Privacy Practices section of this form. All existing laws regarding client access to mental health information and copies of mental health records apply. Telemenatal health services are provided through the HIPAA complaint, secure software. No permanent video or voice recordings are kept from telemental health sessions. Clients may not record or store videoconference sessions.

CLIENT EXPECTATIONS DURING TELEMENTAL HEALTH SESSIONS

you'll need the following to join a telemental health session with your clinician: A computer, tablet, or phone (no applications or software to download) An external or integrated webcam an external or integrated microphone an internet connection with a bandwidth of at least 10MBPS. we recommend an ethernet cable over WiFi when possible to ensure you receive the best possible connection through your internet provider. it may be helpful to shut down all background applications to ensure your telemental health session receives the majority of your internet's bandwith, especially applications that use your camera access to Google Chrome, Mozilla Firefox or Safari (latest release versions) web browsers proper lighting and seating to ensure a clear image of each participant's face dress and environment appropriate to an in-office visit engage in sessions in a private location where you cannot be heard by others only agreed upon participants will be present and the presence of individuals unapproved by both parties will be cause for termination of the session client must disclose the physical address of their location at the start of the session. Unknown locations will be cause for termination of the session client must provide a phone number where they can be reached in the event of service disruption.

EMERGENCY PROTOCAL

Client is to provide the name and contact information for a local emergency contact. In the case of a mental health emergency during a telemental health session where a client is deemed at imminent risk of harming themselves or someone else, the therapist engaged in the session will contact the client's local emergency services and/or 911. Release of information forms will be completed for necessary entities unless confidentiality must be breached to protect the safety if the client or other identified individual.

RATES AND PAYMENT PROCEDURES

NH Kelly (Neidy Hernandez Kelly) rate for telemental health is the same as the in-session (face-to-face) rates. These sessions are 45-60 minute in length. The length of your specific session is set up between client and therapist prior to each session. All clients must pay for telemental health services using a valid debit/credit card. This credit card is placed on file in our electronic health record for security purposes. It is up to the client to notify NH Kelly (Neidy Hernandez Kelly) of any changes to their debit/credit card information before a new telemental health session begins.

CONSENT FOR TELEMENTAL HEALTH TREATMENT

I hereby consent to engage in telemental health services with NH Kelly (Neidy Hernandez Kelly) and any member of its clinical staff. I understand that telemental health includes mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communication of my medical and mental health information. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.