REBECCA M. FISHAUT, MSW, LICSW, PLLC NOTICE OF 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 THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present, or future physical or mental
health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in
accordance with applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and
Association of Social Workers Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice
of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at
that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request, or providing one to you at
your next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical consult
group members and other treatment team members, who are also bound by privacy rules.
I may use and disclose PHI so that I can receive payment for the treatment services provided to you if you have requested to use your insurance. Examples of payment-related
activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical
necessity, or undertaking utilization review activities.
For Health Care Operations
I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, licensing, and conducting or arranging for
other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing services) provided I have a written contract with the
business that requires it to safeguard the privacy of your PHI.
Required by Law
Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of
investigating or determining our compliance with the requirements of the Privacy Rule.
Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit me to disclose information about you without
your authorization only in a limited number of situations. As a social worker licensed in this state and as a member of the National Association of Social Workers, it is my practice to adhere to
more stringent privacy requirements for disclosures without an authorization.
Child and Elder Abuse or Neglect
I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child and elder abuse or neglect.
Judicial and Administrative Proceedings
I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order, or similar process.
I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior
consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons
that have been deceased for more than fifty (50) years is not protected under HIPAA.
I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to notify you of this disclosure as soon as reasonably
practical after the resolution of the emergency.
Family Involvement in Care
I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include
government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing
utilization and quality control.
I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order, or similar document, for the
purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime
in an emergency, or in connection with a crime on the premises.
Specialized Government Functions
I may review requests from U.S. military command or the Department of State and disclose your PHI based on your written consent, mandatory disclosure laws, or the need to prevent serious harm.
If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of
preventing or controlling disease, injury, or disability, or, if directed by a public health authority, to a government agency that is collaborating with that public health authority.
I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a
serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
PHI may only be disclosed after a special approval process or with your authorization.
I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already
made a use or disclosure based upon your authorization.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to Privacy Officer, Rebecca M. Fishaut, MSW, LICSW at 1417
NW 54th St., Ste 334, Seattle, WA 98107.
Right of Access to Inspect and Copy
You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains
mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations
where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable,
cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another
Right to Amend
If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for
amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you
have any questions.
Right to an Accounting of Disclosures
You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month
Right to Request Restrictions
You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless
the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid
for out of pocket. In that case, I am required to honor your request for a restriction.
Right to Request Confidential Communication
You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information
regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. You may choose not to provide
explanation of why you are making the request.
If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
Right to a Copy of this Notice
You have the right to a copy of this notice.
If you believe I have violated your privacy rights, you have the right to file a complaint in writing with the Privacy Officer, Rebecca M. Fishaut, MSW, LICSW at 1417 NW 54th St., Ste 334,
Seattle, WA 91807 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. I
will not retaliate against you for filing a complaint.
The effective date of this Notice is July 9, 2021.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you
are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices for Rebecca M. Fishaut, MSW, LICSW.