Coastal Counseling Associates

24 Front Street, Exeter, NH 03833

(603) 778-0505, Fax – (603) 772-6761

www.coastalcounseling.com

NOTICE OF PRIVACY PRACTICES

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

Your client file may contain personal information about you health and/or the health of your children. This information may identify you if referred to as Protected Health Information (PHI). This notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices. We reserve the right to change the terms of our Privacy Practices and will inform you if we do so.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

For Services: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members.

For business Operations: We may use or disclose, as needed, your PHI in order to support of business activities such as confirming appointments, coverage, billing, accounting, collections, quality assurance and utilization review. We do require that outside consultants sign a privacy contract to help insure confidentiality.

All other uses and disclosures of PHI will be made only with your written authorization with the following exceptions.

• When required by law, such as the mandatory reporting of child abuse or neglect, imminent danger, or mandatory audits from government agencies or boards.
• Required by Court Order

Your Rights Regarding Your PHI

• The right to request restrictions on certain uses and disclosures, including those to family members, other relatives, close friends or others identified by you. We are, however, not required to agree to a requested restriction. If we do agree a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of PHI.
• The right to inspect and copy your PHI
• The right to request an amendment of your PHI
• The right to receive an accounting of disclosures of PHI
• The right to obtain a paper copy of this notice from us upon request

Complaints: If you believe we have violated your privacy rights, you have the right to file a complaint in writing with CCA’s Privacy Officer or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington D.C.

CCA PRIVACY NOTICE

I hereby acknowledge that I have received and read CCA’s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights I can contact CCA’s Privacy Officer at 24 Front Street, Exeter, NH.

Signature of Client Date

Signature of Parent/Guardian Date

**Client refuses to acknowledge Receipt:

Signature of Staff Date