When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

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 health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the contact page.
• You can file a complaint with the U.S. Department of Health and Human 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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

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.

• You have both the right and choice to tell us to:

(1) Share information with your family, close friends, or others involved in your care
(2) Share information in a disaster relief situation
(3) 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 the following cases we never share your information unless you give us written permission:

(1) Marketing purposes
(2) Sale of your information
(3) Most sharing of psychotherapy notes

• In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.

We typically use or share your health information in the following ways.

Treat you
• 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.

Run our organization
• 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.

Bill for your 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.

Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research
• We can use or share your information for health research.

Comply 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.

Respond to organ and tissue donation requests
• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your health information?
• For more information on other ways we are allowed or required to share your information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

In addition to the above information, based on the federal Health Insurance Portability and Accountability Act (HIPAA), as a mental health provider within the state of Indiana, TBH also complies with the following state laws regarding the release of mental health records to the patient and other authorized persons.

Maintenance of Records
• TBH is required to maintain a record for each patient receiving mental health services. The information contained in the mental health record belongs to the patient involved as well as to the provider. TBH shall maintain the original mental health record for at least seven (7) years.

Confidentiality – A patient’s mental health record is confidential and are typically disclosed only with prior consent of the patient. However, information with the health record can be disclosed without prior consent under the following circumstances, in accordance with IC 16-39-3:
• A client’s mental health records may be released in investigations and legal proceedings if a court orders the release of the patient’s mental health record after finding, by a preponderance of the evidence that: (1) other reasonable methods of obtaining the information are not available or would not be effective; and (2) the need for disclosure outweighs the potential harm to the patient.
• Upon the written request of the parent, guardian, or court appointed special guardian who is involved in the planning, provision, and monitoring of the mental health of a child enrolled in a school, the provider shall provide the child’s school principal or school leader with information as described in IC 16-39-2-3, in accordance with those provisions.
• Other disclosures permitted without the client’s consent can be found in IC 16-39-2-6.

Provider’s use of records
• Except as provided in IC 16-39-4-5, the original health record of the patient is the property of the provider and as such may be used by the provider without specific written authorization for legitimate business purposes, including the following:
o Submission of claims for payment from third parties;
o Collection of accounts;
o Litigation defense;
o Quality assurance;
o Peer review;
o Scientific, statistical, and educational purposes
• In the execution of the above legitimate business purposes, the provider shall at all times protect the confidentiality of the health record and may disclose the identity of the patient only when disclosure is essential to the provider’s business use or to quality assurance and peer review.

Patient access; restrictions; appeal
• A patient is entitled to inspect and copy the patient’s own mental health record. However, if the provider that is responsible for the patient’s mental health records determines for good medical cause, upon the advice of a physician, that the information requested under this section is detrimental to the physical or mental health of the patient, or is likely to cause the patient to harm the patient or another person, the provider may withhold the information from the patient. The patient may appeal the provider’s refusal to permit the patient to inspect and copy the patient’s own record under IC 4-21.5.

Access to patient’s designee or legal representative; written request
• Upon a patient’s written request and reasonable notice, a patient’s mental health record shall be made available for inspection and copying by the provider at any time to an individual or organization designated by the patient or to the patient’s legal representative. A patient’s written request for the release of the patient’s mental health record under this section must include the following:
(1) The name of the patient.
(2) The name of the person requested to release the patient’s mental health record.
(3) The name of the person, provider, or organization to whom the patient’s mental health record is to be released.
(4) The purpose of the release.
(5) A description of the information to be released from the mental health record.
(6) The signature of the patient.
(7) The date the request is signed.
(8) A statement that the patient’s consent to release of mental health records is subject to revocation at any time, except to the extent that action has been taken in reliance on the patient’s consent.
(9) The date, event, or condition on which the patient’s consent to release of mental health records will expire if not previously revoked.

Discovery or admissibility without patient’s consent; Court Ordered Release
• Mental health records are not discoverable or admissible in any legal proceeding without the consent of the patient, except that the court my order the release of the patient’s record without his/her consent upon the showing of good cause following a hearing under IC 16-39-3 or in a proceeding under IC 31-30 through IC 31-40 following a hearing held under the Indiana Rules of Trial Procedure.

Exercise of patient’s rights by others; equal access to records; fees –
• The following persons are entitled to exercise the patient’s rights on the patient’s behalf:
(1) If the patient is a minor, the parent, guardian, or other court appointed representative;
(2) If the provider determines that the patient is incapable of giving or withholding consent, the patient’s guardian, a court appointed representative of the patient, a person possessing a health care power of attorney for the patient, or the patient’s health care representative.
• A custodial parent and a noncustodial parent of a child have equal access to the child’s mental health records unless:
(1) a court has issued an order that limits the noncustodial parent’s access to the child’s mental health records; and
(2) the provider has received a copy of the court order or has actual knowledge of the court order.

If the provider incurs an additional expense by allowing a parent equal access to a child’s mental health records, the provider may require the parent requesting the equal access to pay a fee under IC 16-39-9 to cover the cost of the additional expense.

Decedents’ records; consent to release
• Consent to the release of a deceased patient’s record may be given by the personal representative of the patient’s estate. If there is no appointment of a personal representative, consent may be given by:
(1) the patient’s spouse; or
(2) if there is no spouse, any responsible member of the patient’s family, including a parent, guardian, or custodian of the deceased patient’s minor child.

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

If you have question regarding this Notice of Privacy Practices please contact:

Joshawa Torres, MS LMFT
Owner, Torres Behavioral Health, LLC
260-702-9141
Joshawa.torres@torresbehavioralhealth.com