JESSICA C. SULLIVAN LCSW, PLLC / NOURISH YOUR MIND
NOTICE OF PRIVACY PRACTICES
Effective Date: May 18, 2020

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact:
Jessica Sullivan, the acting Privacy Officer at (845) 547-0479.

This notice of Privacy Practices describes how we may use and disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. Protected Health Information is any information about you that may identify you and that relates to your past, present or future mental health condition. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time and will inform you in writing when doing so. The new notice will be effective for all Protected Health Information that we maintain at that time.

Our Commitment to You: We understand that the information we collect about you and your health is personal. Keeping your health information confidential and secure is one of our most important responsibilities.We keep a record of the care and services you receive at this facility. We need this record to provide you with quality care and to comply with certain legal requirements. We are committed to protecting your health information and to following all state and federal laws regarding the protection of your health information.

This notice tells you how we may use or release your health information. It also tells you about your rights and our requirements concerning the use and disclosure of your health information.
We are required by law to:

• make sure that health information that identifies you is kept private
• give you this notice of our legal duties & privacy practices with respect to health information about you
• follow the terms of the notice that is currently in effect

Your Health Information Rights: You have the following rights regarding health information we have about you:

RIGHT to Inspect and Obtain Copies: You have the right to inspect and obtain a copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records. It does not include information that is needed for civil, criminal, or administrative actions or proceedings. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. To inspect or obtain a copy health information that may be used to make decisions about you, you must submit your request in writing to Jessica Sullivan, LCSW. We may deny your request to inspect and obtain a copy in very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. A Medical Records Access Review Committee will review your request and the denial. The person(s) conducting the review will not include the person who denied your request. We will comply with the outcome of the review.


RIGHT to Amend: If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend that information. We may deny your request if you ask to amend information that: (1) was not created by us; (2) is not part of the health information kept by us; (3) is not part of the information which you would be permitted to inspect or copy; or (4) is determined to be accurate and complete. You have the right to request an amendment for as long as the information is kept by or for us.To request an amendment, your request must be made in writing and submitted to Jessica Sullivan, LCSW. In addition, you must provide a reason that supports your request.


RIGHT to an Accounting of Disclosures: You have the right to request a list of information releases that we have made of your health information. The list will not include: health information releases: (1) made for purposes of providing treatment to you, obtaining payment for services, or releases made for other administrative or operational purposes; (2) made for national security; (3) made to correctional and other law enforcement custodial situations; (4) made based on your written authorization; (5) made to persons who are involved in your care; or (6) made prior to April 14, 2003. To request this list or accounting of disclosures, you must submit your request in writing to Jessica Sullivan, LCSW. Your request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

RIGHT to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for the purpose of treatment, payment, or health care operations. You also have the right to request that we restrict or limit health information about you that we may use or disclose to someone who is involved in your care or the payment for your care, such as a family member. For example, you could ask that we not use or disclose information about the medication you are taking to your spouse or significant other. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to Jessica Sullivan, LCSW. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).

RIGHT to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at a certain phone number or by mail. To request confidential communications, you must make your request in writing to Jessica Sullivan, LCSW. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.


RIGHT to a Paper Copy of this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.You may obtain a copy of this notice at our website, www.nourishyourmind.com. To obtain a paper copy of this notice, please contact Jessica Sullivan, LCSW.

Uses and Disclosure of Protected Health Information:

Written Consent. Information will be disclosed to third parties with your expressed written consent. Your counselor may request that you sign a consent form to obtain records from other parties who have treated you, are currently treating you or to other agencies when referrals are made on your behalf to another agency. This written consent may be revoked by you at any time by notifying your counselor or the Privacy Officer in writing. In all cases, the consent will expire 12 months from the date that you signed the consent. We will also disclose information to a third party if they provide us with written consent from you to do so. You may specify, on the consent form, the information you wish us to obtain or release.

Treatment. Caregivers, such as nurses, doctors, therapists and social workers, may use your health information to determine your plan of care. Individuals and programs within our organization may share health information about you to coordinate the services you may need, such as clinical services, therapy, nutritional services, hospitalization, or transfers or referrals for follow-up care. We may use health information about you to provide you with treatment or services.

Payment. Your Protected Health Information will be used as needed to obtain payment for your health care services. This may include any activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you or for making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you, or undertaking utilization review activities. You may request that we restrict the use of your Protected Health Information and disclosure of same for treatment, payment or health care operations, but we are not required to agree with the restriction. If we do agree with the restriction, we will not violate that agreement, except in cases of emergency.

Operations. We may use or disclose, as needed, your Protected Health Information, in order to support the business activities of Jessica C Sullivan LCSW, PLLC / Nourish Your Mind. These activities include, but are not limited to, quality assurance activities, counselor review activities, activities and reviews relevant to licensing issues with any agency involved in our licensing or funding. We may use your Protected Health Information, as necessary to contact you by telephone or letter for issues related to appointment reminders or appointment setting or to inquire about your intent to continue services.

Keep You Informed. Unless you provide us with alternative instructions, we may contact you about reminders for treatment, medical care, or health check-ups. We may also contact you to tell you about health related benefits or services that may be of interest to you or to give you information about your health care choices.

Government Agencies Providing Benefits or Services. We may release your health information to other government agencies that are providing you with benefits or services when the information is necessary for you to receive those benefits or services.

Required by Law. We may use or disclose your Protected Health Information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified as required by law of any such uses or disclosure. This includes, but is not limited to disclosure that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your Protected Health Information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. We may also disclose Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes. We may disclose Protected Health Information in the course of any judicial or administrative proceedings, in response to an order of a court or administrative tribunal, in response to a subpoena, in response to a discovery request or other lawful process.

Avert a Serious Threat to Health or Safety. We may release your health information if it is necessary to prevent a serious threat to your health or safety or to the health and safety of the public or another person.

Criminal. We may disclose your Protected Health Information in the event that a crime occurs on the premises of the agency. Consistent with applicable federal and state laws, we may disclose your Protected Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or to the public. (refer to Confidentiality Section of Consent to Services). We may also disclose Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual.

What is NOT Covered Under this Notice?

• Confidential HIV Related Information: Under New York State law, confidential Human Immunodeficiency Virus (HIV)-related information (information concerning whether or not you have had an HIV-related test, or have HIV infection, HIV-related illness, or Acquired Immune Deficiency Syndrome (AIDS), or which could indicate that a person has been potentially exposed to HIV, can only be given to entities allowed to have it by law or allowed to have it by a release that you have signed.
• Alcohol or Substance Abuse Treatment Information: If you have received alcohol or substance abuse treatment from an alcohol/substance abuse program that receives funds from the United States government, federal regulations may protect your treatment records from disclosure without your written authorization.

Complaints. You have the right to file a complaint with the Privacy Officer of Nourish Your Mind or with the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. Nourish Your Mind will not retaliate against any person who files a complaint or exercises any other right under the privacy rule. A complaint may be filed with the Privacy officer at Nourish Your Mind by calling 845-547-0479 or send your complaint to:

Office for Civil Rights
U.S. Department for Health and Human Services 200 Independence Ave Room 509F HHH Building
Washington, DC 20201
Or call OCR Hotline: (800)-368-1019

If you have any questions about this notice, please contact:
Jessica Sullivan, the acting Privacy Officer at (845) 547-0479.