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Crescent Counseling Services is a division of Aldridge Palay Group

AP © 2015. All rights reserved.
Contact AP: 01 614 787 0544
167 South State Street Suite 50 Westerville, OH 43081

Crescent Counseling Notice of Provacy Practices.
This notice explains how Lara Palay, LISW-W of Crescent Councnseling, a division of Aldridge Palay Group, uses and discloses (shares) your health information. It also explains your health information rights.

You will receive this Notice of Privacy Practices on your first service encounter with Ms Palay.

You will be asked to acknowledge receipt of this notice.

OUR LEGAL OBLIGATIONS
We have a legal obligation to:
• Maintain the privacy of your Protected Health Information. Protected Health Information (“health information”) is health information that individually identifies you.
• Inform you about our legal duties and privacy practices related to your past, present and future health information.
• Follow the terms of this notice as currently in effect.

HOW WE MAY USE AND DISCLOSE (SHARE) YOUR HEALTH INFORMATION
The following describes the ways we may use and disclose (“share”) your health information. All other uses and disclosures will require your written authorization or the written authorization of your legal health care representative.
Treatment/Care
• We may use and share your health information to provide, coordinate and manage your treatment and any related services. This includes the coordination or management of your health care with outside providers. This happens only when necessary and you will be involved in the decision to do so.
Payment of Your Treatment/Care
• We may use and share your health information for payment of services provided by us or another provider. For example, your health information may be disclosed to your health plan for determination of coverage or payment of a bill.
Practice Operations
• We may use and share your health information to support our operational and business activities. For example, your health information may be used and shared to conduct quality assessment and review activities. We may also contact you to remind you of an appointment.
• We may share your health information for functions and services provided by our Business Associates. For example, we may share your health information with a company to perform billing services on our behalf. Business Associates and their subcontractors are obligated by law to protect the privacy of your health information. You may also ask us about any Business Associate Agreements we currently have in place.
Individuals Involved in Your Care or Payment for Your Care
• When appropriate, we may share your health information with a person who is involved in providing or paying for your care, such as a family member, close friend or legal health care representative. You may opt out of this disclosure as outlined in this notice.
As Required by Law
• We will share your health information when required to do so by international, federal, state or local law; statutes; regulations; court orders.
To Avert a Serious Threat to Health or Safety
• Your health information may be shared to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures will be made only to someone who may be able to help prevent or lessen the threat (including the target of the threat).
Essential Government Functions
• Your health information may be shared with authorized federal officials for:
o conducting intelligence, counter intelligence and national security activities;
o providing protective services to the President of the United States;
o making medical determinations for U.S. State Department employees;
o determining eligibility for or conducting enrollment in certain government benefit programs; and
o military purposes (for example, if you are a member of the armed forces, we may release your health information as required by military command authorities).
Law Enforcement (Federal, State, Local)
• Your health information may be shared with a law enforcement official if the information is:
o required by law;
o to identify or locate a suspect, fugitive, material witness, or missing person;
o to report the victim or suspected victim of a crime or death resulting from criminal activity (this includes suspected abuse, neglect or domestic violence;
o to report the commission and nature of a crime, location of crime or crime victims, and the perpetrator of a crime (this includes crimes occurring on our premises).
• We may share your health information if you are an inmate of correctional facility.
Health Oversight Activities
• We must share your health information with government agencies for legally authorized activities such as audits, investigations, and civil or criminal proceedings.
Public Health Activities
• We may share your health information for public health activities such as:
o the prevention or control of disease, injury or disability;
o to report births and deaths;
o to report adverse reactions to medications or problems with products;
o to notify people of recalls of products they may be using;
o to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
• While we may share your health information for these and other similar public health needs we are not responsible for monitoring such information.
Additional State and Federal Requirements
Some state and federal laws provide additional privacy protection of your health information. We will always seek your permission and or inform you of the need to release any information to anyone, including in these additional areas. These include:
• Sensitive Information. Some types of health information are particularly sensitive, and the law, with limited exceptions, may require that we obtain your written permission or in some instances, a court order, to use or disclose that information. Sensitive health information includes information dealing with genetics, HIV/AIDS, mental health, sexual assault and alcohol and substance abuse.
• Information Used in Certain Disciplinary Proceedings. State law may require your written permission if certain health information is to be used in various review and disciplinary proceedings by state health oversight boards.
• Information Used in Certain Litigation Proceedings. State law may require your written permission for us to disclose information in certain legal proceedings.
• Disclosures to Certain Registries. Some laws require your written permission if we disclose your health information to certain state‐sponsored registries.
Worker’s Compensation
• Your health information may be shared with Worker’s Compensation or similar programs as necessary to provide benefits for work related injuries or illness.
Decedents
• In the event of your death, we may share your health information with:
o a person who was involved in providing or paying for your care, such as a family member, close friend or legal health care representative;
o a coroner or medical examiner as necessary to identify a deceased person or determine the cause of death.
• Health information is not subject to privacy protection 50 years following the date of your death.
Research
• Under certain circumstances, we may use or disclose health information about you for research purposes. For example, we might disclose your health information for use in a research project involving the effectiveness of certain clinical procedures or approaches. In some cases, we might disclose your health information for research purposes without your knowledge or approval. However, such disclosures will be made only if approved through a special process. This process evaluates a proposed research project and its use of health information, and balances the research needs with your need for privacy of your health information. We may combine conditional and unconditional authorization for research if we differentiate between the two activities and allow for unconditional research activities. Future research studies may be part of a properly executed authorization which includes all of the required core elements of an authorization.
Marketing
• Your health information will be shared for marketing purposes without an authorization only when:
o the communication is face‐to‐face with you; or
o promotional gifts of nominal value (e.g., pamphlet) are provided by us.
• Any other uses of your health information for marketing purposes will require your written authorization or the authorization of your legal healthcare representative. You may opt out of this disclosure as outlined in this notice.
Change of Ownership
• In the event that the practice is sold or merged with another organization, your health information will become the property of the new owner although you will maintain the same rights with respect your health information.
Data Breach Notification
• We may use or share your health information to provide legally required notices of an unauthorized breach (access) of your unsecured health information.
• In the event of a breach of your unsecured health information, you will be notified by us. You may also be notified by one of our Business Associates or their subcontractors.
Psychotherapy Notes
• Psychotherapy notes will be maintained with in strict confidence.
o Written notes will be kept in a locked and secure filing cabinet in a located office within the larger locked office suite. The building is also locked during non-business hours.
o Electronic copies will be held on a password-protected computer and a password protected back-up hard drive kept at a secured second location.
• Your psychotherapy notes will not be shared without your permission unless required by law as outlined in this policy.
• Your psychotherapy notes will not be shared with persons who are involved in providing or paying for your care, such as a family member, close friend or legal health care representative without your written permission.
• Your psychotherapy notes will not be used in any marketing.
• Your psychotherapy notes will not be shared in case of a disaster unless you have already given or you give written permission.
Sale of Protected Health Information
• Your health information will not be sold without written authorization from you or your legal health care representative.

YOUR OPPORTUNITY TO OPT OUT OF CERTAIN USES AND DISCLOSURES
You may Opt Out of the following uses and disclosure of your health information.

Individuals Involved in your Care or Payment for Your Care
• Unless you Opt Out, we may share your health information with a person who is involved in providing or paying for your care such as a family member, close friend or legal health care representative.
Disaster Relief
• We may share your personal health information with disaster relief organizations to coordinate your care or notify your family and friends of your location or condition in a disaster. You will be provided with an opportunity to object to such a disclosure whenever it is feasible to do so.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The Right to Access Your Own Health Information
• With certain exceptions outlined by privacy regulations, you have the right to review and copy your health information and billing records.
• To review or obtain a copy of your health information, you or your legal health care representative must submit your request in writing.
• We have up to 30 days from the time of your written request to make your health information available to you. We may charge you a reasonable fee based on our costs to copy and mail your health information. You may ask for the cost in advance of the information being prepared.
• In very limited circumstances, we may deny your request. If we deny your request, you will receive written notification of the denial. You have the right to appeal the denial by submitting a written appeal request. Your appeal request will then be reviewed by a licensed clinical professional not directly involved in your care or in the denial of your request for access to your health information. You will be notified in writing regarding the outcome of that appeal. In some cased the licensed clinical professional may charge a fee for the review and response. You will be expected to pay that fee. You may ask for the cost in advance of the information being prepared. Instead of or in addition to this procedure you may contact the Counselor, Social Worker and Marriage and Family Therapist Board as indicated in your service agreement.
• All written requests should be sent to APG, 3953 Bluebird Court, Westerville, OH 43081.
The Right to Amend Your Health Information
• If you believe your health information is incorrect or incomplete, you have the right to request that we amend (change) the information as long as the information was created by us.
• To request an amendment of your health information, you or your legal health care representative must submit a request to change information in your record stating
o the amending you are requesting (change, deletion, addition),
o the exact amending you are requesting, and
o the reason(s) for amending your health information.
• We will respond within 60 days.
• If your request is approved, we will place your written request in your health record and correct your health information to reflect the approved amendment.
• We may deny your request if the existing health information is correct and complete, was not created by us, or is not available for inspection. If your request is denied, we will notify you in writing and include the reason(s) for the denial. We will explain your right to file a written statement of disagreement with the denial. Instead of or in addition to this procedure you may contact the Counselor, Social Worker and Marriage and Family Therapist Board as indicated in your service agreement.
• All written requests should be sent to APG, 3953 Bluebird Court, Westerville, OH 43081.
The Right to an Electronic Copy of Electronic Medical Records
• If your health information is maintained in an electronic record (known as an electronic medical record or electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your health information in the form or format you request. We may charge you a reasonable fee based on our costs for the labor associated with preparing and transmitting the electronic health information.
The Right to an Accounting of Certain Disclosures of Your Health Information
• You have the right to request a list of certain disclosures of your health information. The list will not include disclosures made:
o for purposes of treatment, payment, or health care operations;
o to you, your caregivers or your legal health care representative;
o for which you or your legal health care representative provided a written authorization;
o for national security or intelligence purposes;
o to correctional institutions or law enforcement officials;
o for purposes of research or public health when direct patient identifiers are not used;
o as required by law;
o to an oversight agency in certain circumstances.
• By law, the maximum period the list must cover is 6 years immediately preceding the written request for an accounting of certain disclosures. Any disclosure prior to the implementation of a tracking mechanism will be provided on a separate document.
• You may be charged a reasonable fee based on our costs for the labor associated with preparing the accounting of disclosures.
• To request an accounting of disclosures of your health information, you or your legal health care representative must submit a written request.
• All written requests should be sent to APG, 3953 Bluebird Court, Westerville, OH 43081.
The Right to Request Restrictions of Your Health Information
• You have the right to request a restriction or limitation on how we use or disclose your health information. However, you may not restrict or limit the uses that are required by law.
• You have the right to restrict disclosure of your health information to your health plan when you have paid out of pocket and in full for the service unless the disclosure is required by law.
• To request a restriction of your health information, you or your legal health care representative must submit a written request.
• All written requests should be sent to APG, 3953 Bluebird Court, Westerville, OH 43081.
The Right to Choose How We Share Your Health Information with You
• You have the right to request, in writing, that we communicate your health information in a certain way or at a certain location. For example, you may request that we only contact you by mail or at work.
• We will accommodate reasonable and feasible requests.
The Right to a Paper Copy of this Notice
• You have the right to a paper copy of this notice, and may request a paper copy of this notice at any time, even if you agreed to receive this notice electronically.
• Requests can be made by telephone or electronically or sent to APG, 3953 Bluebird Court, Westerville, OH 43081.

REVISIONS TO THIS NOTICE OF PRIVACY PRACTICES
We reserve the right to make revisions to the terms of this notice as required by law. Revised notices will be made available to you.

IF YOU HAVE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
• If you feel your privacy rights have been violated or you disagree with a decision we made about your health information rights, contact us immediately by phone or electronically or in writing at APG, 3953 Bluebird Court, Westerville, OH 43081.
• You may also contact the Ohio Counselor, Social Worker and marriage and Family Therapist Board as indicated in your service agreement.
• You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. within 180 days of a violation of your rights. We will not retaliate against you for filing a complaint.

EFFECTIVE DATE
This Notice of Privacy Practices is effective September 23, 2014.
Below is the Crescent Counseling Notice of Privacy Practices. To request an electronic copy please click here.
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