Privacy Practices

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!

Pass Go! Therapy and Coaching, is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment.

It also includes billing documents for those services. Example of Use of Your Health Information for Payment Purposes: We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.

My pledge regarding health information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice in effect.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of healthcare providers with a third party, consultations between healthcare providers, and referrals of a patient for healthcare from one healthcare provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful processes 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.

Certain uses and disclosures require your authorization

1. Psychotherapy Notes. I do not keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Example of Use of Your Information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services. Your Health Information Rights The health and billing records we maintain are the physical property of the office. The information in it, however, belongs to you.

You have a right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request to our office — we are not required to grant the request, but we will comply with any request granted;

• •Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full—we must comply with this request;

• Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office;

• Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to our office;

• Appeal a denial of access to your protected health information, except in certain circumstances;

• Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office. We may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

• Is not part of the health information kept by or for the office;

• Is not part of the information that you would be permitted to inspect and copy; or is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;

• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office;

• Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.

• Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office in person, or by mail, except to the extent information or action has already been taken.

• Elect to opt out of receiving further fundraising communications from the office

If you want to exercise any of the above rights, please contact Pass Go! Therapy and Coaching LLC at 202-743-0072 by phone, or in writing, during regular, business hours.

We will inform you of the steps that need to be taken to exercise your rights. Our Responsibilities

Pass Go! Therapy and Coaching, LLC, is required to:

• Maintain the privacy of your health information as required by law;

• Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;

• Abide by the terms of this Notice;

• Notify you if we cannot accommodate a requested restriction or request; and,

•  Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

Version. February 2023