Notice of Privacy Practices
Notice of Health Care Service Provider Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW HEALTH CARE, PSYCHOLOGICAL, AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
• Treatment is when Ashley Thompson, LPC, LPCC provides, coordinates or manages your mental health care and other services related to your mental health care. An example of treatment would be when Ashley Thompson, LPC, LPCC consults with another health care provider, such as your family physician or another therapist or psychologist.
• Payment is when Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy provides you with a paid invoice so you can pursue out-of-network or FSA reimbursement for your mental health care. Examples of payment are when Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy discloses your PHI on your paid invoice which will be emailed to you directly. In signing this form, you are giving your consent to receive a paid invoice via email and are assuming the potential risk of your PHI being exposed. In doing so you release Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy from fault. If you wish to receive your paid invoice through the Simple Practice EHR and do not wish to receive an emailed paid invoice, you must notify Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy in writing.
• Health Care Operations are activities that relate to the performance and operation of Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy. Examples of mental health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may use or disclose PHI for purposes outside of treatment, payment, and mental health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy is asked for information for purposes outside of treatment, payment and mental health care operations, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will obtain an authorization from you before releasing this information.
Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes Ashley Thompson LPC, LPCC have made about conversations during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may use or disclose PHI without your consent or authorization in the following circumstances:**
Child Abuse:** If Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy has reasonable cause to suspect that a child seen in the course of professional duties has been abused or neglected, or have reason to believe that a child seen in the course of professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy must report this to the relevant county department, child welfare agency, police, or sheriff’s department.
Adult and Domestic Abuse: If Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy believes that an elder person has been abused, or neglected, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may report such information to the relevant county department or state official of the long-term care ombudsman.
Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy release records to them in order for the Psychology Examining Board to investigate a complaint, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy must comply with such a request.
Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will not release the information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance, if this is the case.
Serious Threat to Health or Safety: If Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy has reason to believe, exercising professional care and skill, that you may cause harm to yourself or another, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy must warn the third party and/or take steps to protect you, which may include instituting commitment proceedings.
Worker’s Compensation: If you file a worker's compensation claim, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may be required to release records relevant to that claim to your employer or its insurer and may be required to testify.
IV. Client’s Rights and Health Care Provider’s Duties:
Client’s Rights:
1. Right to Request Restrictions–You have the right to request restrictions on certain uses and disclosures of protected health information about you. You have the right to restrict disclosure of PHI to a health plan with respect to health care for which you have paid out-of pocket and in full. However, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy is not required to agree to all restrictions you request.
2. Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will discuss with you the details of the request process.
3. Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may deny your request. On your request, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will discuss with you the details of the amendment process.
4. Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will discuss with you the details of the accounting process.
5. Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
6. Right to Electronic Copy—You have the right to request and receive a copy of your PHI if stored electronically in a designated record set.
7. Right to Timely Response—You have the right to receive your PHI in 30 or fewer days after we receive your request, whether in a paper or electronic format. Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy may request one 30-day extension to provide your PHI, but will give you notice if this occurs.
8. Right to Prohibit Sale of PHI—You have the right to prohibit the sale of your PHI without your express written authorization.
9. Right to Notification of Breach—You have a right to be notified if there is a breach of unsecured PHI.
10. Right to Reasonable Fee—You have a right to receive your PHI information, but may be charged a reasonable, cost-based fee to cover costs of copying or labor to compile, scan, etc. records.
Health Care Provider’s Duties:
• Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
• Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy reserves the right to change the privacy policies and practices described in this notice. Unless Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy notifies you of such changes, however, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy is required to abide by the terms currently in effect.
• If Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy revises its policies and procedures, Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will provide individuals with a revised notice.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy makes about access to your records, or have other concerns about your privacy rights, you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services, the State of Wisconsin Department of Safety and Professional Services or the State of California Board of Behavioral Sciences. You have specific rights under the Privacy Rule. Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will not retaliate against you for exercising your right to file a complaint.
Wisconsin Department of Safety and Professional Services Division of Legal Services and Compliance
P.O. Box 7190 Madison, WI 53707-7190
Fax: (608) 266-2264
Email: dsps@wisconsin.gov
State of California Board of Behavioral Sciences
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916) 574-7830
You have specific rights under the Privacy Rule. Ashley Thompson Therapy LLC will not retaliate against you for exercising your right to file a complaint.
VI. Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on January 10, 2024. Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. Ashley Thompson Licensed Professional Clinical Counselor Inc DBA Ashley Thompson Therapy will provide you with a revised notice.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.