This notice describes how mental health information about you may be used and disclosed and how you can get
access to this information. Please read it carefully.
Effective Date: March 15, 2004.
Introduction to Privacy
We are required by law to maintain the privacy of your medical information. We are also required to give you this
Notice about our privacy practices, our legal duties and your rights concerning your mental health information. We
must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to
change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by
law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective
for all medical information that we maintain, including medical information we created or received before we made
the changes. If we make a significant change in our privacy practices, we will amend this Notice and make the new
Notice available upon request.
Joint Notice Of Privacy
This Joint Notice applies to the privacy practices of the entities participating with Restoration & Peace Counseling
described below for the sole purpose of complying with Medicaid and other insurance guidelines. These entities
are viewed as participating in a joint arrangement for the sole purpose of assuring payment for certain insurance
carriers. These Affiliated Entities include:
· Donna Stewart, LMHP, Ph.D. (Medicaid Clients)
· Felicia Frezell, Billing
The Affiliated Entities participating with Restoration & Peace may share your mental health information with each
other as necessary to carry out treatment and payment.
Uses and Disclosures of Medical Information
We use and disclose medical information about you for treatment and payment.
Treatment: We may use and disclose your mental health information to a physician or other
health care provider in order to provide treatment to you. This includes coordination of your care with other health
care providers, and with health plans, consultation with other providers, and referral to other providers related to
your care. To help clarify these terms here are some definitions.
-Treatment is when we provide, coordinate, or manage your health care and other services related to your health
care. An example of treatment would be when we consult with another health care provider, such as your family
physician or another psychologist.
-Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose
your Personal Health Information to your health insurer to obtain reimbursement for your health care or to
determine eligibility or coverage.
-Health Care Operations are activities that relate to the performance and operation of my practice. Examples of
health care operations are quality assessment and improvement activities, business-related matters such as
audits and administrative services, and case management and care coordination.
Payment: We may use and disclose your mental health information to obtain payment for services we provide to
you. Payment includes submitting claims to health plans and other insurers of the care we deliver to you,
determining your eligibility for health plan benefits for the care we furnish to you, obtaining pre-certification or
pre-authorization for your treatment or referral to other health care providers, participating in utilization review of
the services we provide to you and the like. We may disclose your mental health information to another health
care provider or entity subject to the federal Privacy Rules so they can obtain payment.
We may disclose your medical information to another provider or health plan that is subject to the Privacy Rules,
as long as that provider or plan has a relationship with you and the mental health information is for their health
care quality assessment and improvement activities, competence and qualification evaluation and review
activities, or fraud and abuse detection and prevention.
On Your Authorization: You may give us written authorization to use your mental health information or to disclose
it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Unless you
give us a written authorization, we cannot use or disclose your mental health information for any reason except
those described in this Notice.
To Your Family & Friends: We may disclose your mental health information to whomever you give us permission.
Before we disclose your information to a person involved in your health care or payment for your health care, we
will provide you with an opportunity to object to such uses or discloses. If you are not present, or in the event of
your incapacity or an emergency, we will disclose your mental health information based on our professional
judgment of whether the disclosure would be in your best interest.
Business Associate: We may disclose your mental health information to a company or individual performing
functions or activities to or on behalf of one or more of the Affiliated Entities who may have access to or be given
your health information in order to provide the contracted services.
Marketing: We will NOT use your mental health information for marketing purposes without your authorization. We
must obtain your authorization for all marketing purposes except for face-to-face conversations about services
and treatment alternatives. You may also receive information through a Restoration & Peace program that you
have expressed interest in. If you no longer wish to receive further information, please indicate this in writing to
Restoration & Peace.
Fund-raising: We may use your demographic information and the dates of your health care to contact you for
fund-raising purposes. If you would not like your demographic information shared or would not like to receive
fund-raising communications, please indicate this in writing.
Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes
deemed to be in the public interest or benefit:
· Public Health activities including disease and vital statistics reporting, child abuse reporting, adult protective
services and FDA oversight
· Health Oversight Agencies
· In response to court and administrative orders and other lawful processes
· To law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims,
suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or
locating a suspect or other person
· To coroners, medical examiners and funeral directors
· To avert a serious threat to health or safety
· To correctional institutions regarding inmates
· To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities,
and to correctional institutions and law enforcement regarding persons in lawful custody
Individual Rights
You have the right to review or receive a copy of your mental health information, with limited exceptions. You may
request that we provide copies in a format other than photocopies. We will use the format you request unless we
cannot practicably do so. You must make a request in writing to obtain access to your mental health information.
You may obtain a form the facility where you obtain your mental health care. There is a charge for a copy of your
information.
Accounting of Disclosures
You have the right to receive an accounting of all uses and disclosures of your mental health information that was
not authorized by you and that was not used, by an Affiliate Entity or Restoration & Peace or a business
associate, for the sole purposes of treatment and payment. You must request this accounting in writing. This
accounting is maintained for a period of 6 years beginning on March 15, 2004, the effective date of this Notice.
You may obtain this accounting by submitting your request in writing.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your
mental health information. We are not required to agree to these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency). You must make this request in writing.
Confidential Communications: You have the right to request that we communicate with you about your mental
health information by alternative means or to alternative locations. You must make your request in writing. We
must accommodate your request if: it is reasonable; specifies the alternative means or location; and provides a
satisfactory explanation of how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your mental health information. Your request must be
in writing, and it must explain why the information should be amended. We may deny your request if we did not
create the information you want amended and the originator remains available or for certain other reasons. If we
deny your request, we will provide you a written explanation. You may respond with a statement or disagreement
to be appended to the information you want amended. If we accept your request to amend the information, we will
make reasonable efforts to inform others; (including people you name) of the amendment and to include the
changes in any future disclosures of that information
Security of Your Information
Restoration & Peace safeguards client information using various tools such as passwords and data encryption,
files are double locked in accordance with state guidelines. We continually strive to improve these tools to meet
or exceed industry standards. We also limit access to your information to protect against its unauthorized use.
The only Restoration & Peace employees who have access to your information are those who need it as part of
their job. These safeguards help us meet both federal and state requirements to protect your personal health
information.
Questions or Concerns
If you have questions about this notice, disagree with a decision we make about access to your records, or have
other concerns about your privacy rights, you may contact Tracey Lynn Pearson, MSW, PLMHP @ Restoration &
Peace @ 402.573.0858
If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send
your written complaint to the board of directors of OWMNCO Inc. (One Way Ministry National Community
Outreach Inc.) 6008 Grand Ave. Omaha, NE 68104. This is the first level governing board of Restoration &
Peace Counseling.
You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services.
We can provide you with the appropriate address upon request.
