NOTICE OF HIPAA PRIVACY PRACTICES & ELECTRONIC COMMUNICATION AGREEMENT
From Provider: Riverwood Psychotherapy LLC
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.
RIVERWOOD PSYCHOTHERAPY LLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.
YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.
To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.
To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.
To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.
To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.
To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.
To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.
To 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.
To file a complaint if you feel your rights are violated.
• You can file a complaint by contacting the Practice using the following information:
Riverwood Psychotherapy LLC, 3439 SE Hawthorne Blvd # 947, Portland, OR 97214-5048, TEL. (971) 460-1676
• 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/.
• The Practice will not retaliate against you for filing a complaint.
To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.
OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:
To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.
To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.
To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.
2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:
To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.
To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.
To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.
3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:
To your family, friends, or others if PHI directly relates to that person's involvement in your care.
If it is in your best interest because you are unable to state your preference.
4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:
Marketing, sale of PHI, and psychotherapy notes.
You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in this Notice unless you give your permission in writing.
OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website https://riverwoodpsych.com/notice-of-privacy-practices/.
• The Practice will inform you if PHI is compromised in a breach.
This Notice is effective on November 4, 2024.
RIVERWOOD PSYCHOTHERAPY LLC ELECTRONIC COMMUNICATION AGREEMENT
THIS NOTICE DESCRIBES HOW THE PROVIDER, or “PRACTICE,” COMMUNICATES WITH YOU, the “CLIENT,” VIA ELECTRONIC COMMUNICATION.
RIVERWOOD PSYCHOTHERAPY LLC, an OREGON limited liability corporation (“we”, “us” or “Practice”) and the undersigned client (“you” or “Client”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as e-mail, mobile or cellular telephone (if applicable), Google Meet, Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication (collectively “E- Communication”) with respect to Client protected health information (“PHI”). (Practice and Client are each individually called “Party” or collectively as “Parties”).
CLIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH
While Practice and Client commonly rely on electronic communication platforms and services to achieve immediate communication, there are risks that you acknowledge that are outside the Practice’s control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otherwise in writing. You acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any absolute guarantee of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/ recipients, technology failures, and user errors.
You agree to undertake efforts to protect your privacy, which include refraining from including sensitive information in E-Communications that you do not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect your privacy to the extent required by applicable laws. You authorize us to respond electronically to all E-Communications that appear to be provided by you, whether or not such communications arrive from the electronic contact information that you provide us.
CLIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION
You agree to provide us with your accurate electronic contact information (email address, Skype or FaceTime contact information, and any other applicable E-Communication contact information). You will immediately inform us of any changes or corrections to your electronic contact information as an effort to avoid misdirected E-Communications. You will also inform us of your permanent mailing residential address, and any changes to that address.
CLIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM
Practice does not guarantee that we will read your E-Communications immediately or within any specific amount of time. You agree not to utilize E-Communications to contact us regarding an emergency or time- sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency, immediately seek emergency medical attention, or both.
HIPAA/HITECH/DATA PRIVACY LAWS
Practice values and appreciates your privacy and will take commercially reasonable steps to protect Client’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws such as HITECH (collectively referred to as “HIPAA”). Practice shall also comply with other data privacy laws related to Client’s data.
We will obtain your express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward your identifiable PHI to any third party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law. You hereby consent to the use of E- Communication of Client's information as we consider it helpful to coordinate care and schedule mobile visits with you and all those responsible for providing or overseeing your care. You agree to identify individuals or entities authorized to receive your PHI from us in connection with authorized consulting, education, and all other aspects of your care, and we may share your PHI with such parties without additional written or electronic consent from you.
You have the right to ask us for a copy of your PHI, including an explanation or summary. The following services will not be the subject of any additional charges to you (and are outside Services Fees): maintaining PHI storage systems; recouping capital or expenses for PHI data access, PHI storage, and infrastructure; or retrieval of PHI electronic information.
Practice may charge you fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include, to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media (with media costs charged to you); and time spent by our administrative staff preparing additional explanations or summaries of PHI. If you request PHI on a paper copy, or portable media (such as compact disc/CD, universal serial bus/USB flash drive), we may charge you for our actual supply costs for such equipment, and you agree to pay us any such costs.
CLIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS
You will hold Practice (and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees arising out of or caused by E-Communication (whether encrypted or not) losses or disclosures caused by any of the risks outlined above, by some person or entity other than Practice, or not directly caused by us. Client acknowledges and understands that, at our discretion, E-Communication may or may not become part of your permanent medical record. These terms do not relieve Practice from Practice's obligations to comply with all applicable E-Communication laws.
You acknowledge that your failure to comply with the terms of this EC Agreement may result in our terminating the use of E-Communication methods with you and may cause the termination of your Agreement for our services.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are required to provide you a copy of our Notice of Privacy Practices, which states how we may disclose your health information. You hereby acknowledge receipt of the Notice of Privacy Practices.
CONSENT TO DISCLOSURE OF BILLING INFORMATION
By signing this EC Agreement, you consent to Practice disclosing all information relevant to billing, insurance, and reimbursement regarding any and all substance abuse disorders that you might have, for the purpose of obtaining reimbursement from private or public insurers.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
ADDITIONAL TERMS
This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.
Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by you. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.
Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties further agree that this EC Agreement cannot be changed, modified or discharged except by an agreement in writing and signed by both Parties.
If any term of this EC Agreement is deemed invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall remain in full force and effect, and this EC Agreement shall be deemed amended to conform to any applicable law.
Each participating Client (and authorized representative when applicable) must sign this EC Agreement. Your signature represents that you understand and agree to the terms and conditions described within this EC Agreement.
This Notice is effective on November 17, 2024.