Faith Winters, 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

PROTECTING YOUR PERSONAL HEALTH INFORMATION

I am committed to the privacy of your personal information, I am required by applicable federal and state laws to maintain the privacy of your personal and health information. Personal health information means any information that is identifiable to you as your personal information, including information regarding your healthcare and treatment; identifiable factors including your name, age address, income or financial information; in the form of written, electronic or spoken words.

As of April 14, 2003 I will follow the privacy practices that are described in this notice while it is in effect.

COLLECTING YOUR PERSONAL INFORMATION

I collect your personal information from you for the purpose of clinical case management, and billing both you and your insurance (if applicable). I protect your personal information by:

• Treating all of the information I collect as confidential.
• Stating confidentiality policies and practices in my Professional Disclosure Statement as well as disciplinary measures for privacy violations.
• Restricting access to your personal information only to those contracted to handle your information in order to provide you with services, such as paying a claim for a covered service.
• Only disclosing your personal information necessary for a service company to perform its function on our behalf, and the company agrees to protect and maintain the confidentially of your personal information.
• Maintain physical, electronic and procedural safeguards that comply with federal and state regulations to guard your personal information.
• Your personal information will not be disclosed unless I am allowed or required by law to make disclosure or if you or your authorized representative gives me permission.
• Anything beyond those listed below require your authorization. If there are other legal requirements under applicable state laws that further restrict my use or disclosure of your personal information, I will comply with those legal requirements as well.

Following are the types of disclosure I may make as allowed or required by law:

• Treatment: I maintain your personal information for treatment and supervision activities.
• Payment: I may use and disclose your personal information for our payment activities.
• Business Associates: I may share your personal information with my administrative assistant, for third party payment or to send a bill directly to you. I require this person to afford your personal information the same protections afforded by me.
• Plan Sponsors and Underwriting: if you are enrolled in a group health plan, I may disclose your personal information to the sponsor to permit it to perform administrative activities relating to your benefits, benefit payment and your contract of health insurance/benefits.
• To You or Your Authorized Representative: Upon your written request, I will disclose your personal information to you or your named authorized representative or entity. You may revoke your authorization in writing at any time. Your revocation won’t affect any use or disclosures permitted by your authorization while it was in effect. In certain situations when disclosure of your information could be harmful to you or another person, I may limit the information available to you, or use an alternative means of meeting your request.
• To Your Parents, if you are a Minor: Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians, and persons acting similar legal status. I will act consistently with the laws of Oregon, and make disclosure consistent with Oregon law.
• Family and Friends: If you are unable to consent to the disclosure of your personal information, such as in a medical emergency. I may disclose your personal information to a family member or a friend to the extent necessary to help you with your health care or with payment for your treatment.
• Health-related services: I may use your personal information to contact you about health-related services: newsletters, treatments, groups, seminars or treatment alternatives that may be of interest.
• Public Health and Safety: I may disclose your personal information if I believe disclosure is necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. I may disclose your personal information if I believe that you are a possible victim of abuse, neglect, domestic violence or other crimes.
• Required by law: I must disclose your personal information when I am required to do so by law.
• Process and Proceedings: I may disclose your personal information in response to a court or administrative order, subpoena, discovery request, or other lawful process.
• Law Enforcement: I may disclose limited information to law enforcement.
• Military and National Security: I may disclose to military authorities the personal information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials personal information for lawful intelligence, counterintelligence, and other national security activities.

WHAT RIGHTS DO YOU HAVE AS AN INDIVIDUAL REGARDING OUR USE AND DISCLOSURE OF YOUR PERSONAL INFORMATION?

You have the right to request all of the following:
Access to your personal information: You have the right to review and receive a copy of your personal information. I may charge you a nominal fee for providing you with copies of your personal information. This right doesn’t include the right to obtain copies of the following records:
Psychotherapy notes: information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to other state or federal laws that prohibit me to release such information I may also limit your access to your personal information if I determine that providing the information could possibly harm you or
another person, you have the right to request a review of that decision. .
Amendment: You have the right to request that I amend your personal information. Your request must be in writing, and it must identify the information that you think is incorrect and explain why the information should be amended. I may decline your request for certain reasons, including if you ask me to change information that I did not create. You may respond with a statement of disagreement to be appended to the information you want amended. If I accept your request to amend the information, I will make reasonable efforts to inform others, including people you have authorized, of the amendment and to include in any future disclosure of that information.
Accounting of Disclosures: You have the right to receive a report of instances in which I, or my business associates disclosed your personal information for purposes other than for treatment, health care operations, and certain other activities. You are entitled to such an accounting for the 6 years prior to your request, though not for disclosure made prior to April 14, 2003. I will provide you with the date on which I made a disclosure, the name of the person or the entity to whom I discussed your personal information, a description of the personal information I disclosed, the reason for the disclosure, and other applicable information. If you request this list more than once in a 12 month period, I may charge you a reasonable fee for creating and sending these additional reports.
Limiting Disclosure: You have the right to request additional restrictions on my disclosure of any personal information. You have the right to restrict disclosure of information to insurance carriers, third party payers, health care operations or to any persons who you identify. In rare circumstances I may be unable to restrict a specific disclosure.
Confidential Communication: You have the right to request that I communicate with you in confidence about your personal information by alternative means or to an alternative location. If you advise me that disclosure of all or part of your personal information could endanger you, specify an alternative means of communication.

Grievance Procedures: If you feel my services to you can he improved, I urge you to discuss your concerns with me, the treating therapist. If you feel that I do not adequately address your concerns, I encourage you to use the following Grievance Procedure:

1. Please submit the grievance as soon as possible.
2. Submit the grievance in writing to me, your treating therapist. I will consult with another Associate.
3. If you are not satisfied with the response from me, or if you do not receive a response from me within 10 days, you may request a review by the Consulting Associate. This request must be in writing and must be delivered within 10 days from the date you receive or should have received my response.
4. The Consulting Associate will investigate the facts and will respond to you in writing within 10 days of the receipt of your request for review.
5. If you are not satisfied with the response from the consulting Associate or if you do not receive a response from the Consultant within 10 days, you may request an arbitration with an agreed upon third party. This request must be in writing and must be delivered within 10 days from the date you receive or should have received the Consulting Associate’s response.

I reserve the right to change my privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable by law.

If you want additional information or further explanation regarding my privacy practices, you may contact me, Faith Winters, LLC at (503) 267-3149.