Psychiatric Intake Form Page 9
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11Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.
20201, calling 1-877-696-6775, or visiting We will not retaliate
against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we
share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your
instructions. In these cases, you have both the right and choice to tell us to:
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Share information with your family, close friends, or others involved in your care
•
Share information in a disaster relief situation
•
Include your information in a hospital directory If you are not able to tell us your preference, for example if you
are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may
also share your information when needed to lessen a serious and imminent threat to health or safety. In these
cases we never share your information unless you give us written permission:
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Marketing purposes
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Sale of your information
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Most sharing of psychotherapy notes
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In the case of fundraising:
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We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health in- formation in
the following ways:
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We can use your health information and share it with other professionals who are treating you. Example: A doctor
treating you for an injury asks another doctor about your overall health condition.
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We can use and share your health information to run our practice, improve your care, and contact you when
necessary. Example: We use health information about you to manage your treatment and services.
•
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
•
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that con- tribute to the public
good, such as public health and research. We have to meet many conditions in the law before we can share your
information for these purposes. For more information see:
We can share health in- formation about you
for certain situations such as:
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Preventing disease
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Helping with product recalls
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Reporting adverse reactions to medications
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Reporting suspected abuse, neglect, or domestic violence
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Preventing or reducing a serious threat to anyone’s health or safety
•
Do research
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We can use or share your information for health research.
Compliance with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human
Services if it wants to see that we’re complying with federal privacy law.
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We can share health information about you with organ procurement organizations
2.
We can work with a medical examiner or funeral director
3.
We can share health information with a coroner, medical examiner, or funeral director when
an individual dies
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