Jane McCampbell Stuart

This notice pertains to THERAPY clients and describes how health-related information about you may be used and disclosed under the Federal Health Insurance Portability and Accountability Act (HIPAA).

Effective Date: January 1, 2022

OBLIGATIONS & COMMITMENT TO YOU

Jane McCampbell MA, LMFT takes the privacy of your health information seriously. The information collected about you and your mental and physical health issues is considered “private”, and is protected by state and federal laws. This information is referred to as “Protected Health Information” or “PHI” and includes information in your record that could identify you such as your name, address or date of birth.

Jane McCampbell not only follows all state and federal laws protecting your PHI, but also attempts to limit any disclosure of information about you to the minimum necessary. It is further expected that any consultants, volunteers or business partners working with Jane McCampbell will also respect your privacy and abide by the same laws.

Jane McCampbell creates a record of your care in order to supply you with quality care and to document services for legal and billing purposes. This notice informs you of the ways that your PHI may be disclosed and to whom, and what rights you have.

HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED

Described as follows are the ways Jane McCampbell may use and disclose health information that identifies you, with your authorization:

• For treatment: It may be necessary to consult with a doctor, medical specialist or another therapist you are seeing to provide the most effective treatment. Such exchanges of information require your written consent.
• For payment: In order to be reimbursed for services, your health insurance company requires details of your diagnosis, the number of sessions in which you participate and potentially other information such as your treatment plan. Such information is used to determine eligibility for coverage.
• For health care operations: Your information may be utilized for normal health care operation, such as entry into a billing system.
• To contact you: Unless otherwise specified by you, your information may be used to contact you by telephone, voicemail or email in order to return a message or relay information to you.

Described as follows are special situations in which your Personal Health Information may be used or disclosed without your consent or authorization.

• As required by law: Information will be disclosed when required by federal, state, or local law. For example, therapists are obligated by law to report suspected abuse or neglect of a child or vulnerable adult.
• To avert a serious threat to health or public safety: Information will be disclosed when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person. However, disclosures in these areas will only be made to someone who may be able to prevent the action and only will involve discussion about issues relevant to the threat.
• Lawsuits and Other Disputes: If you are involved in a lawsuit or a dispute, information may be disclosed in response to a court order if signed by a judge. Any other disclosures of Personal Health Information in response to subpoena, discovery request, or other lawful process by someone else involved in the dispute, must have your written permission.
• Health Oversight Activities: Information may be disclosed for purposes of health oversight regarding health-care delivery as authorized by law. These activities may include insurance audits or investigations. The Minnesota Board of Marriage and Family Therapy may request records from Jane McCampbell if they are relevant to an investigation it is conducting. If your written permission has not been received, your identifying information will be concealed.
• Worker’s Compensation: Information may be disclosed as authorized by and to the extent necessary to comply with worker’s compensation laws or laws relating to similar programs.

SPECIAL USES AND DISCLOSURES REQUIRING AUTHORIZATION

Jane McCampbell may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when information is requested for purposes outside of treatment, payment, health care operations or those required by law, Jane McCampbell will obtain an authorization from you before releasing this information. Such an authorization is required to release psychotherapy notes, which are given a greater degree of protection than PHI.

YOUR RIGHTS

You have the following rights regarding the Protected Health Information held about you:

• The right to request restrictions on certain uses and disclosures of protected health information. However, Jane McCampbell is not required to agree to a requested restriction.
• The right to receive confidential communications of PHI, for example, to receive phone calls and written communication at specified addresses and phone numbers.
• The right to inspect and copy PHI, including notes and reports, as provided in the Privacy Regulation. These requests must be made in writing.
• The right to amend PHI, as provided in the Privacy Regulation. These requests must be made in writing and may be denied for reasons provided in the Privacy Regulation.
• The right to receive an accounting of disclosures of PHI. This request must be in writing.
• The right to a paper copy of this Notice at any time.

REQUESTING COPIES OF YOUR PHI

You have a right to request, in writing, a copy of your patient record in accordance with Minnesota Statute 144.292. Unless the file information is requested for a review of your current medical care, a worker’s compensation claim or a Social Security disability claim, you will be charged a per-page copy fee, a retrieval fee, and the cost of any shipping required. 2021 rates set by the Minnesota Department of Health allow for a per-page copy fee of $1.46 and a retrieval fee of $19.42. Jane McCampbell will provide you with an estimate prior to making copies. In order to receive your file, you will first need to make full payment for copies, retrieval and shipping via PayPal at www.paypal.me/therapyjane. Please note that HIPAA regulations allow providers up to 30 days to retrieve, prepare and dispatch requested information.

REQUESTING COPIES OF YOUR PHI FOR LEGAL DISPUTES

Jane McCampbell is a therapist and coach. She does not offer forensic psychology services and cannot provide evaluations, diagnoses or offer opinions for the purposes of personal injury, emotional distress, worker’s compensation or disability claims. Since the legal affairs of current and former clients create a significant distraction from Jane McCampbell’s primary business, an administrative fee of $450 per hour or part thereof will be billed for any time spent responding to requests for her involvement or resisting disclosure on a client’s behalf. Clients will also be held responsible for any attorney fees incurred by Jane McCampbell during the process. Requests for copies of records for any purposes other than continuing medical/mental health care or Social Security disability claims will be billed according to the schedule allowed by the Minnesota Department of Health.

CHANGES TO THIS NOTICE

Jane McCampbell is required to abide by the terms of the Notice currently in effect, and reserves the right to change this Notice and to make the new notice apply to the Health Information already held as well as any information received in the future. Revised Notices are made available at www.therapyjane.com.

QUESTIONS/COMPLAINTS

If you have any questions about this Notice, or are concerned that your privacy rights have been violated you may contact Jane McCampbell, MA, LMFT on 612 414 0383. You may also send a written complaint, without penalty, to the Secretary of the U.S. Department of Health and Human Services or the Minnesota Board of Marriage and Family Therapy.