Last Updated on April 12, 2017. This privacy policy is effective immediately.

You now have the right to restrict certain disclosures of Protected Health Information (PHI) by Kentlands Psychotherapy to your insurance carrier or health plan.

Without this restriction your insurance company or other payer may access your entire record. To exercise this right you must choose to pay out-of-pocket in full. To exercise this right, simply talk to your doctor. You may be surprised by how little this costs.


If you consent, the provider 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, test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:

  • An employee of the provider’s office obtains treatment information about you and records it in a health record.
  • During the course of your treatment, the provider determines that he/she will need to consult with another specialist in the area. He/She will share the information with such specialists and obtain his/her input.

An example of use of your health information for payment purposes:

  • We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding services rendered. We will provide that information to them about you and the care you receive.
  • We verify insurance coverage prior to your first appointment and obtain prior authorization and precertification when required to do so by your policy coverage.
  • We provide information to agents we retain to collect past due fees.

An example of use of your health information for health care operations:

  • The state licensing authority wants to review records to assure that we have acted consistent with state law regarding your care. In doing so, it wants to take a sampling which includes review of your chart. At the licensing authority’s request, we will provide it with a copy of your chart.
  • Employees and Business Associates of Kentlands Psychotherapy may access and/or share protected health information.

YOUR HEALTH INFORMATION RIGHTS:

The health record and billing records we maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:

  • Request a restriction on certain uses and disclosures of your protected health information by delivering the request in writing to our office. We are not required to grant the request, but we will comply with any request that is granted.
  • Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office.
  • Request that you be allowed to inspect and receive a copy of your health record and billing record in electronic or other mutually agreeable form. You may exercise this right by delivering the request in writing to our office using the form we provide to you upon request.
  • Appeal a denial of access to your protected health information.
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request.
  • File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
  • Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. The accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request.
  • 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 using the form we provide to you upon request.
  • Revoke any authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
  • You now have the right to be notified if there is breach of certain unsecured information.

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.

If you want to exercise any of the above rights, please contact your therapist at 240-252-3349, in person, or in writing, during normal business hours. She will provide you with assistance on the steps to take to exercise your rights.

OUR RESPONSIBILITIES:

The provider 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.
  • Accommodate your reasonable requests regarding methods to communicate health information to 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 to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.

To File a Complaint

You may also file a complaint by mailing or e-mailing it to the Secretary of Health and Human Services at 202-619-0257 We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Uses and Disclosures

  • We have Business Associates with whom we may share your protected health information.
  • For example, in preparing our annual financial statement, auditors may need to review samples of medical care given.
  • For example, during our routine health care operations, we may need to hire computer technicians and software vendors. We may disclose your health information to these vendors to maintain daily functioning in our health care operations.
  • We use Virtual PBX for our phone system.
  • We use a scheduling platform called Schedulicity.
  • Our website, hosted by Madwire has a contact us form.
  • Microsoft 365 is hosting our email.

Notification
Unless you object in writing, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other persons responsible for your care including any doctor who you inform us is involved in your care, about your location, about your general condition, about your diagnosis and treatment or your death.

Communication with Family
Unless you object in writing we may discuss scheduling and billing with your family member. Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors/Coroners
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Marketing
Unless you object in writing we may contact you via mail, email, or phone to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits or services that may be of interest to you.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse and Neglect
We may disclose your protected health information to public authorities as allowed or required by law to report abuse or neglect.
Correctional Institutions If you are an inmate of a correctional institution, we may disclose to the institution or agents there of your protected health information necessary for your health and the health and safety of other individuals.

Law enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, or as directed by a proper court order. To avert a serious threat or health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Contact Information

To ask questions or comment about this privacy policy and our privacy practices, contact your clinician or Dr. Elizabeth Carr, Founder.

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