Notice of Privacy Practices
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.
Pledge Regarding Mental Health Information
privacy of your mental health information is critically important to us. We understand that your mental health information is personal
and we are committed to protecting it.
create a record of care and the treatment you receive at our practice.
We maintain this record to provide you with quality care and to comply
with certain legal requirements. This
Notice will tell you about the ways we may use and share mental health
information about you. We also
describe your rights and certain duties we have regarding the use and disclosure
of protected mental health information.
and Disclosure of Your Protected Mental Health Information
following section describes different ways that we use and disclose protected
mental health information. Not
every use and disclosure will be listed. However,
we have listed all the different ways we are permitted to use and disclose
mental health information.
will not use or disclose your mental health information for any purpose not
listed below without your specific written authorization.
Any specific written authorization you provide may be revoked at any time
by writing to us.
of use of your mental health information for Treatment purposes:
We obtain treatment information about you and record it in a health
Disclosures and Uses required or permitted by law include:Abuse & Neglect:
All licensed Marriage and Family therapists are mandated by
Connecticut State Law to report suspected abuse and neglect of children, the
elderly, and persons with disabilities.
Proceedings: We may disclose
your protected mental health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your specific
written consent, or as directed by a Judge’s Court Order.
To avert a life-threatening situation, we may disclose your protected
mental health information consistent with applicable law to prevent an imminent
threat to the health or safety of a person or the public.
Law Enforcement: We may disclose your protected mental health information for law
enforcement purposes as required by law, such as when required by a Judge’s
Court Order. We do not routinely
release protected mental health information in response to an attorney’s
In the event of an emergency, hospitalization, and with your permission,
we may use or disclose your protected mental health information to notify, or
assist in notifying, a family member, personal representative, or other person
responsible for your care, about your location, and about your general
If you are seeking compensation through Workers Compensation, we may
disclose your protected mental health information to the extent necessary to
comply with laws relating to Workers Compensation.
Health Information Rights
health and billing records we maintain are the physical property of Wine Trail Behavioral Health, LLC. The
information in it, however, belongs to you.
You have a right to:
a restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office.
We are not required to grant the request but we will carefully review any
a paper copy of the Notice of Privacy Practices for Protected Health Information
by making a written request at our office;
that you be allowed to inspect and copy your mental health record and billing
record – you may exercise this right by delivering the request in writing to
our office using the form we provide to you upon your written request. Payment of one dollar per page will be charged for
reproducing your mental health record. If
you are a parent or a legal guardian of a minor, please note that certain
portions of the minor’s mental health record will not be accessible to you.
In those situations where your clinician determines that access to your
record would be harmful, your clinician will restrict your access to the record.
a denial of access to your protected health information except in certain
circumstances. The Clinical Director of Wine Trail Behavioral Health, LLC. will conduct
the appeal and review the nature and purpose of the written request and
determine whether the disclosure of certain information contained in your mental
health record may be deleterious to your condition or impede further treatment
of your condition. This decision
will be binding.
that your mental health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office.
(We are not required to make such amendments);
a statement of disagreement if your amendment is denied, and require that the
request for amendment and any denial be attached in all future disclosures of
your protected health information;
an accounting of disclosures of your health information as required to be
maintained by law by delivering a written request to our office.
An accounting will not include internal uses of information for
treatment, or payment, or disclosures made to you at your request.
that communication of your health information be made by alternative means or
alternative location by delivering the request in writing to our office; and,
authorizations that you made previously to use or disclose information except to
the extent information or action has already been taken by delivering a written
revocation to our office.
have the right to review the Notice before signing the consent authorizing use
and disclosure of your protected health information for treatment, payment and
health care operations purposes.
Wine Trail Behavioral Health, LLC. is required to: Maintain the privacy of your
health information as required by law; Provide you with a notice as to our
duties and privacy practices as to the information we collect and maintain about
you; Abide by the terms of this Notice; Notify you if we cannot accommodate a
requested restriction or request; and Accommodate your reasonable requests
regarding methods to communicate health information with you.
reserve the right to amend, change, or eliminate provisions in our privacy
practices and access practices and to enact new provisions regarding the
protected health information we maintain. If
our information practices change, we will amend our Notice.
You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our “Notice” or by visiting our office and picking up a
Request Information or File a Complaint
you have questions, would like additional information, or want to report a
problem regarding the handling of your information, you may contact us at 203-317-7446.
You may also file written complaints with the Director,
Office of Civil Rights of the U.S. Department of Health and Human Services. Wine Trail Behavioral Health, LLC. will not retaliate against you if you
file a complaint.
cannot, and will not require you to waive the right to file a complaint with the
Department of Health and Human Services (HHS) as a condition of receiving
treatment from the office.
notice is effective on January 21, 2011.