NOTICE OF PRIVACY PRACTICES – YOUR INFO. YOUR RIGHTS. – OUR RESPONSIBILITY.
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.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
– You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask AG Behavioral Services how to do this.
– AG Behavioral Services will provide a copy or a summary of your health information, usually within 30 days of your request. They may charge a reasonable, cost-based fee.
Ask AG Behavioral Services to correct your medical record
– You can ask AG Behavioral Services to correct health information about you that you think is incorrect or incomplete. Ask them how to do this.
– They may say “no” to your request, but will tell you why in writing within 60 days.
Request confidential communications
– You can ask AG Behavioral Services to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
– They will say “yes” to all reasonable requests.
Ask AG Behavioral Services to limit what they use or share
– You can ask AG Behavioral Services not to use or share certain health information for treatment, payment, or their operations.
– They are not required to agree to your request, and may say “no” if it would affect your care.
Get a list of those with whom AG Behavioral Services has shared information
– You can ask for a list (accounting) of the times AG Behavioral Services has shared your health information for six years prior to the date you ask, who they shared it with, and why.
– They will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked them to make). They’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
– You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. AG Behavioral Services will provide you with a paper copy promptly.
Choose someone to act for you
– If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
– AG Behavioral Services will make sure the person has this authority and can act for you before they take any action.
File a complaint if you feel your rights are violated
– You can complain if you feel AG Behavioral Services has violated your rights by contacting them using the information provided.
– You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
– AG Behavioral Services will not retaliate against you for filing a complaint.
YOUR CHOICE
For certain health information, you can tell AG Behavioral Services your choices about what they share. If you have a clear preference for how they share your information in the situations described below, talk to them. Tell them what you want them to do, and they will follow your instructions.
OUR USES AND DISCLOSURES
How do AG Behavioral Services typically use or share your health information?
– They typically use or share your health information in the following ways…
– Treat you: AG Behavioral Services can use your health information and share it with other professionals who are treating you.
– Run their organization: AG Behavioral Services can use and share your health information to run their practice, improve your care, and contact you when necessary.
– Bill for your services: AG Behavioral Services can use and share your health information to bill and get payment from health plans or other entities.
How else can AG Behavioral Services use or share your health information?
– AG Behavioral Services is allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research.
OUR RESPONSIBILITIES
AG Behavioral Services is required by law to maintain the privacy and security of your protected health information.
– They will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
– They must follow the duties and privacy practices described in this notice and give you a copy of it.
– They will not use or share your information other than as described here unless you tell them they can in writing. If you tell them they can, you may change your mind at any time. Let them know in writing if you change your mind.
CHANGES TO THE TERMS OF THIS NOTICE
AG Behavioral Services can change the terms of this notice, and the changes will apply to all information they have about you. The new notice will be available upon request, in their office, and on their website.
If you have any questions about this notice or any complaints about AG Behavioral Services’ privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact AG Behavioral Services at: 725 River Road, Ste 32, #313 Edgewater, NJ 07020.
If you are not satisfied with the response or resolution provided by AG Behavioral Services, you may also contact the New Jersey Department of Human Services at 222 South Warren Street, PO Box 700, Trenton, NJ 08625-0700.