Hippa Privacy Practices at the Office of David W. Sprague
Effective April 14, 2003


This notice describes how confidential psychological information about you may be used and disclosed and how you can get this information.

Uses and Disclosures:

With your permission, your health information may be disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing mental/medical conditions, and providing treatment.

Payment: Your health information may be used to seek payment from your health plan or from other sources of coverage such as an automobile insurer. For example, your health information plan may request and receive information on dates of services and the psychological condition being treated.

Law Enforcement: Psychological information may be released if requested by a law enforcement officer

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, offices are required to report certain communicable diseases to the state's public health department.

Health Related Benefits and Services: Health information may be used and disclosed to tell you are benefits or services that may be of interest to you.

Individuals Involved in your Care or Payment of you Care: Information may be released to a friend or family member who is involved in your mental health care. Information may also be given to someone who helps you pay for your care. In addition, health information may be disclosed to an entity assisting in a disaster relief effort so that your familty can be notified about your condition, status, and location.

To Avert a Serious Threat to Health or Safety: Information may be released to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, will be made only to someone able to help prevent the threat.


Special Situations:

Military or Veterans: If you are a member of the armed forces, health information may be released as required by military command or authorities.

Workers Compensation: Information maybe be released for worker's compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, information may be released in response to a court or administrative order. Information may also be release in response to a judicial subpeonia, discovery request, or other lawful process by someone else involved in the dispute.

Other Uses and Disclosures Require your Written Authorization: Disclosure of your mental health information, or its use for any purpose other than those listed above, requires your written authorization by signing a confidential release of information document. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of 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 the office of your decision.


Additional Uses of Information

Individual Rights: You have certain rights under the federal privacy standards. These include:

Right to Revise Privacy Practices: As permitted by law, the office reserves the right to amend or modify its privacy policy and practices. These changes in the policies and practices may be required by changes in state and federal laws and regulations. Whatever the reason for these revisions, the office will provide you with a revised notice on the next office visit. The revised policies and practices will be applied to all protected health information the office maintains.

Request to Inspect Protected Health Information: As permitted by federal regulation, requests to inspect or copy protected health information must be submitted in writing. You may obtain a form to request access to your records by contacting the office

If you believe that your privacy rights have been violated, you should call this matter to attention by sending a letter describing the cause of your concern to the office at 113 Main St, Batavia, NY 14020. You will not be penalized or otherwise retaliated against for filing a complaint.


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