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.
Axen Behavioral Health, PLLC ("the practice," "I," "me") is required by law to maintain the privacy of your protected health information, to provide you with this notice of my legal duties and privacy practices, and to notify you following a breach of unsecured protected health information. I am required to follow the terms of this notice currently in effect.
HOW I MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
Treatment. I may use your health information to provide, coordinate, or manage your psychiatric care. This includes sending prescriptions to your pharmacy and, with your written authorization, communicating with your therapist, primary care provider, or other treating clinicians.
Payment. I may use and disclose your health information to obtain payment for services. Claims are submitted through Alma, which acts as my business associate for billing and administrative services. This may include sharing your diagnosis and the services provided with your health plan.
Health Care Operations. I may use your health information for activities necessary to run this practice, including quality assessment, licensing, and business management.
Appointment Reminders. I may contact you by phone, text, email, or patient portal to remind you of appointments or discuss scheduling, according to the contact preferences you provide
DISCLOSURES I MAY MAKE WITHOUT YOUR AUTHORIZATION
Connecticut law provides additional protection for mental health records beyond federal requirements. In most circumstances I will not disclose your psychiatric information without your written consent. The law permits or requires disclosure without your authorization in these situations:
Serious threat to health or safety. If I believe there is a serious and imminent threat to your safety or the safety of another person, I may disclose information necessary to prevent harm.
Suspected abuse or neglect. I am a mandated reporter under Connecticut law and must report suspected abuse or neglect of a child, an elderly person, or a person with a disability.
Legal proceedings. I may disclose information in response to a court order. I will not release records based on a subpoena alone without your authorization or a court order.
As required by law. Including public health reporting, health oversight activities, and reporting to the Connecticut Prescription Monitoring Program when prescribing controlled substances.
Business associates. Vendors who perform services on my behalf, such as my electronic health record and billing platforms, and who are bound by written agreements to protect your information.
Most other uses and disclosures — including any use of your information for marketing, any sale of your information, and most disclosures of psychotherapy notes — require your written authorization. You may revoke an authorization at any time in writing, except to the extent I have already acted on it.
YOUR RIGHTS
Access. You may inspect and obtain a copy of your health record. Request it in writing. I will respond within 30 days. A reasonable, cost-based fee may apply for copies.
Amendment. You may request that I amend information you believe is incorrect or incomplete. Request it in writing with the reason for the request. I may deny the request, and if I do, you may submit a statement of disagreement to be included in your record.
Accounting of disclosures. You may request a list of certain disclosures I have made of your health information, other than for treatment, payment, or operations.
Restrictions. You may request that I limit how I use or disclose your information. I am not required to agree to most requests, but I must agree to a request not to disclose information to your health plan about a service you paid for in full out of pocket.
Confidential communications. You may request that I contact you in a specific way or at a specific location — for example, only by cell phone, or without leaving voicemail. I will accommodate reasonable requests.
Paper copy. You may request a paper copy of this notice at any time, even if you received it electronically.
Breach notification. You will be notified if a breach occurs that compromises the privacy or security of your information.
MY RESPONSIBILITIES
I am required by law to maintain the privacy and security of your protected health information, to notify you promptly if a breach occurs, and to follow the duties and privacy practices described in this notice. I will not use or share your information other than as described here unless you tell me in writing that I may.
CHANGES TO THIS NOTICE
I may change the terms of this notice, and the changes will apply to all information I hold about you. The revised notice will be posted at axenbh.com/privacy-practices with a new effective date and made available on request.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with me. You will not be retaliated against in any way for filing a complaint.
Contact: Ali Khan, PMHNP-BC — Privacy Officer Axen Behavioral Health, PLLC 281 Hartford Turnpike, Suite G-3 Vernon, CT 06066 860-341-2837 hello@axenbh.com
You may also file a complaint with the U.S. Department of Health and Human Services: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue SW Washington, D.C. 20201 1-877-696-6775 hhs.gov/hipaa/filing-a-complaint