NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: December 9, 2024

This Notice of Privacy Practices (“Notice”) is provided by Chiariello Behavioral Health, P.C. (“CBH,” “we” or “our”) and describes how your medical information may be used and disclosed. We take your privacy very seriously. We are also legally required to maintain the privacy of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”).

Please read this Notice carefully as it contains important information on who we are; how and why we collect, use, and share your PHI; and your rights regarding your PHI. Your PHI is health information about you which someone may use to identify you, that we keep or transmit in electronic, oral, or written form. PHI includes information such as your name; contact information; past, present, or future physical or mental health or medical conditions; payment for health care products or services; or prescriptions.

CHANGES TO THIS NOTICE

We reserve the right to amend this Notice at our discretion and at any time. When we make material changes, we will notify you in a manner in which we regularly interact with you, such as by email, or through a notice on our website’s homepage.  You will also be able to determine the date that our current Policy has become effective, by viewing the Effective Date at the top of this document.

DATA BREACH NOTIFICATION

We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will endeavor to notify you in writing, by first-class mail, or we may email you if you have provided us with your current email address and you have previously agreed to receive notices electronically. In some circumstances, our business associates may provide the notification. In limited situations when we have insufficient contact information, we may provide notice in a legally acceptable alternative form.

YOUR RIGHTS

This section explains your rights regarding your PHI and how these may be exercised. You have the right to:

Get a copy of your PHI. You can ask to see or obtain an electronic or paper copy of the PHI that we maintain about you. You may also request that we provide a copy of your PHI another person designated by you.

To fulfill your access request, we may:

• Require you do make access requests by emailing us at no_reply@cbhtherapy.com;
• Require additional information for requests to provide a copy of your PHI to another person. In such case, the request must be in writing, signed by you, and clearly identify the designated person and where to send the copy of PHI.

We endeavor to respond to your request within 30 days of receipt. If we require more time (up to 60 days total), we will inform you of the reason and extension period in writing. We may charge a reasonable cost-based fee for the costs of copying, mailing, or other supplies associated with your request. Under certain circumstances, we may deny your request for the reasons permitted by applicable law that we will specifically identify for you. You have the right to appeal or file a complaint regarding a denial.

Ask us to correct your medical record. You may ask us to correct or amend PHI that we maintain about you that you think is incorrect or inaccurate. For such requests, the following applies:

• Submit the requests by emailing us at no_reply@cbhtherapy.com;
• Specify the inaccurate PHI and provide a reason that supports your request.

We endeavor to respond to your request within 60 days of receipt. If we require more time (up to 90 days total), we will inform you of the reason and extension period in writing. Under certain circumstances, we may deny your request for the reasons permitted by applicable law that we will specifically identify for you. We will also provide you with a description of how you can complain to CBH, and the Secretary of the U.S. Department of Health and Human Services.

If we deny your request, you will have the right to submit a written statement disagreeing with the denial. If you do not submit a statement of disagreement, you may request that we provide your request for amendment and the denial with any future disclosures of the PHI that is the subject of the amendment. Hammer may prepare a written rebuttal to your statement of disagreement and provide you with a copy. We will append the material created or submitted to your designated record.

Ask us to limit what we use or share. You can contact us via email at no_reply@cbhtherapy.com and request us not to use or share certain PHI for treatment, payment, or operations or with certain persons involved in your care.

We are not required to honor a request to limit the PHI we use or share. However, we will agree to not disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item or service for which you or another person, other than the health plan, paid in full out-of-pocket, unless it is otherwise required by law.

Get a list of those with whom we have shared your PHI. You have the right to request an accounting of certain PHI disclosures that we have made. We will include all the disclosures of PHI that occurred during the six (6) years prior to the request, except for those about treatment, payment, and healthcare operations, and certain other disclosures as provided by law.

For these requests, we endeavor to respond within 60 days of receipt. If we require more time (up to 90 days total), we will inform you of the reason and extension period in writing. We will provide one accounting per year for free. We will notify you about any costs in advance.

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. Before such person can act for you and before we take any action, we may require additional information to confirm the person has the required authority.

Request confidential communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests, and we will not ask for the reason. We require that you contact us via email at no_reply@cbhtherapy.com and provide us with the following information:

• How you wish to be contacted; and
• Where you wish to be contacted.

We may condition the provision of a reasonable request on information as to how payment will be handled and specification of an alternative address or other method of contact.

Make a complaint. If you consider any of our policies or procedures a violation of your rights, you have the right to complain. We will not retaliate against you for filing a complaint. You may either file a complaint:

• Directly to CBH by emailing us at no_reply@cbhtherapy.com; or
• With the Office for Civil Rights at the U.S. Department of Health and Human Services. For more information, please visit https://www.hhs.gov/hipaa/filing-a-complaint/index.html. A complaint may be sent via: Online portal: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

Email: OCRComplaint@hhs.gov

Mail: Centralized Case Management Operations
U.S. Department of Health and Human Services

200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

USES AND DISCLOSURES

The law permits or requires us to use or disclose your PHI for various reasons. We have included some examples in this Notice, but we have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum we need to accomplish our intended purpose.

Uses and disclosures for Treatment, Payment, or Healthcare Operations

• We may use or disclose your PHI and share it with other professionals who are treating you, including doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, we might disclose information about your overall health condition to physicians who are treating you for a specific injury or condition.
• Billing and payment. We may use and disclose your PHI to bill and get payment from health plans or others. For example, we share your PHI with your health insurance plan so it will pay for the services you receive.
• Health care operations.  We may use and disclose your PHI to run our practice, improve your care, and contact you when necessary. For example, we may use your PHI to manage the services and treatment you receive or to monitor the quality of our health care services.

Other Uses and Disclosures

We may share your information in other ways, such as for public health or research purposes. For example, these other uses and disclosures may involve:

• Our business associates. We may use and disclose your PHI to outside persons or entities that perform services on our behalf. The law requires our business associates and their subcontractors to protect your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
• Emergency situations. For example, situations involving serious threats to health or safety.
• Complying with the law. For example, we will share your PHI if the Department of Health and Human Services requires it when investigating our compliance with privacy laws.
• Helping with public health and safety issues.For example, we may share your PHI to report injuries, births, and deaths; prevent disease; report adverse reactions to medications or medical device product defects; report suspected child neglect or abuse, or domestic violence; or avert a serious threat to public health or safety.
• Responding to legal actions. For example, we may share your PHI to respond to a court or administrative order or subpoena, or a warrant.
• Addressing workers’ compensation, law enforcement, or other government requests. For example, we may use and disclose your PHI for workers’ compensation claims; health oversight activities by federal or state agencies; law enforcement purposes or with a law enforcement official; or specialized government functions, such as military and veterans’ activities, national security and intelligence, presidential protective services, or medical suitability.

Authorizations for uses and disclosures

In certain cases, we will not share your information unless you give us your written permission. You have the right to revoke such authorization. CBH requires your written permission prior to sharing your PHI for the following purposes:

• Marketing purposes.
• Research activities.

CONTACT INFORMATION

If you would like general information about your privacy, please http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.  If you have specific questions about our privacy practices and your rights under this Notice, please contact Samantha Chiariello, Privacy Officer, at Chiariello Behavioral Health, P.C.:

Phone: 708-864-4920

Email:  no_reply@cbhtherapy.com