Proudly Serving Montgomery County Maryland
301 Inspiration Lane, Second Floor, Gaithersburg, MD 20878
With your out-of-network arrangement with Kentlands Psychotherapy, you have the right to restrict disclosures of Protected Health Information (PHI) by Kentlands Psychotherapy to your insurance carrier or health plan. Minimum information including your name, home address, birthdate, diagnostic and treatment codes and dates of service must be shared via your superbill medical receipt in order for the receipt submission to be eligible for reimbursement.
Submission of your paid receipts for reimbursement is ENTIRELY at your discretion.
Without this restriction, your insurance company, or alternate payer, may access your entire record when seeing an in-network provider or facility. By paying out-of-pocket in full, you keep complete control over your privacy.
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 example of the use of your health information for payment purposes:
An example of the use of your health information for health care operations:
YOUR HEALTH INFORMATION RIGHTS:
The health record and billing records we maintain are the physical property of this office (if before June of 2019) or within the encrypted SimplePractice system (after 6/1/19). The information in it, however, belongs to you. You have a right to:
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. He or she will provide you with assistance on the steps to take to exercise your rights.
The provider is required to:
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
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 relatives, 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.
We may use and disclose your protected health information to assist in disaster relief efforts.
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
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.
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.
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.
If you are an inmate of a correctional institution, we may disclose to the institution or agents your protected health information necessary for your health and the health and safety of other individuals.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
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.