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HIPPA Form

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 It Carefully.

Uses and Disclosures

Treatment: Our Staff members may disclose your health information to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, laboratory test results and treatment will be available in your medical record to all health professionals who may provide treatment of who may be consulted to treat you.

Payment: Your health information may be used to seek payment from your insurance plan or from other sources such as credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of services, the service provided, and the medical condition being treated.

Health Care Operations: Your health information may be used as necessary to support the day-to day-activities and management of Tiftarea Psychiatric and Counseling Services, LLC For example, we may allow access to your medical information to students working with us; we may call you by name from the waiting room

Law Enforcement: Your health information may be disclosed to Law Enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations and to comply with government mandated reporting suspicion of child abuse, disabled and elderly adult abuse. All staff cooperate with subpoenas/court orders issued by a judge as required by law.

Public Health Reporting: We may disclose your health information to public health agencies as required by law. For example, we are required to report certain communicable diseases to the State’s Public Health Department.

Other Uses and Disclosures: Disclosure of your health information or its use for any purpose other than those listed above require your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation or the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Additional Uses of Information: Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

Individual Rights

You have certain rights under Federal Privacy Standards. These include:

● The right to request restrictions on the use and disclosure of your health information, please inform your doctor/therapist if you would like to restrict your records

● The right to receive confidential communications concerning your medical condition and treatment.

● The right to inspect and copy your protected health information. (Patient Access is limited with regards to psychotherapy notes.) All requests for records must be submitted in writing and may incur a fee for copies

● The right to amend or submit corrections to your protected health information. Requests for amendments to records must be submitted to the clinical director/medical director for review.

● The right to receive an accounting of how and to whom your protected health information has been disclosed.

● The right to receive a printed copy of this notice.

Rights to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy, policies and practices. These changes may be required by changes in Federal or State law and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information

As permitted by Federal Regulations, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Privacy Officer. If you feel your rights/privacy has been violated please contact our privacy officer. Privacy officer information available upon request.

A COPY OF THE ENTIRE PRIVACY PRACTICE POLICIES IS AVAILABLE UPON REQUEST.

I have been given and read the notice of Privacy Practices for Tiftarea Psychiatric and Counseling Services, LLC.

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Tiftarea Psychiatric and Counseling Services, LLC. | Office Address: 223 East 2nd Street Suite B Tifton, Georgia 31794
Phone: 229-339-3721 | Fax: 229-472-9151 | Mailing Address: Post Office Box 1613 Tifton, Georgia 31793
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