Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT [INDIVIDUALS’] MAY BE USED AND DISCLOSED AND HOW [INDIVIDUALS’] CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act (“HIPAA”) - Standards for Privacy of Individually Identifiable Health information (“Privacy Rule”), a U.S. Federal law, establishes a set of national standards for the protection of certain health information. The Privacy Rule standards address the use and disclosure of individuals’ health information, called “protected health information”, by “covered entities”; as well as standards for individuals’ privacy rights to understand and control how their information is used. A complete guide, including additional information, is available from the U.S. Department of Health and Human Services website at www.hhs.gov.
Silverado Counseling Services, LLC (“Silverado”, “We”, “Our”), as a covered entity, and its affiliates are required by law to: (a) maintain the privacy of protected health information (“PHI”); (b) provide individuals with notice of its legal duties and privacy practices with respect to PHI; (c) notify affected individuals following a breach of unsecured PHI.
Silverado must provide this notice in “plain language” and has attempted to do so. This “short version” notice is being provided (“long version” is available upon request) by Silverado to advise individuals: (a) of their rights; (b) that we are required to abide by the terms of the notice currently in effect; (c) that we reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain; (d) that we will provide revised notices.
3. Uses and Disclosures
The following purposes describe different ways that we may use and disclosure PHI. This is not a complete list nor does it include all of the ways Silverado is permitted to use and disclosure PHI.
(A) Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.
We use PHI, either created by our agency or received from another provider through a disclosure, to provide treatment or services to an individual.
We may disclose PHI, either through individual’s consent or authorization, to another provider involved in that individual’s care and treatment. For example: An individual may sign a HIPAA compliant release of information for Silverado to disclose and submit medical records, either in part or its entirety, to another provider who is managing their medications.
(B) Payment encompasses activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.
We may use and disclose PHI to bill and collect payment from an individual, their insurance company, or a third party payer. For example: We may need to provide several pieces of an individual’s PHI such as diagnosis, treatment or service codes, identifiers (such as the individual’s name, address, birth date, contact information, and medical, health plan, or account numbers) on a Health Insurance Claim Form to seek reimbursement from an individual’s insurance carrier. Individual’s insurance carrier may then require Silverado to submit a copy of the medical record to verify services billed were actually received, review services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges.
(C) Health Care Operations are any of the following activities: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity.
We may use and disclosure PHI about an individual that is necessary to run Silverado’s internal agency operations.
Silverado will not contact individuals for any fundraising or marketing purposes.
4. Individual Rights
An individual has a right to adequate notice of the uses and disclosures of PHI that may be made by a covered entity, and the individual’s rights and the covered entity’s legal duties with respect to PHI.
An individual has the right:
(a) to request restrictions on certain uses and disclosures of PHI*; (b) to receive confidential communications of PHI; (c) to inspect and copy PHI**; (d) to amend PHI; (e) to receive an accounting of disclosures of PHI; (f) to obtain a paper copy of this notice upon request, even if the individual has agreed to receive the notice electronically.
*Please be advised that we are not required to agree to a requested restriction.
**Please be advised that Psychotherapy notes are specifically excluded and HIPAA sections do outline grounds for denial.
5. Contact or Complaints
If you have questions or would like additional information, please contact Taylor Weisbender, Office Manager at (801)983-5540 or send a written letter to the address below.
If you believe your privacy rights have been violated, you can file a written complaint with Silverado at the address below. Alternately, you may file a complaint with the U.S. Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Silverado Counseling Services, LLC
PO Box 521207
Salt Lake City, UT 84152
6. Implementation Specifications
Silverado must make its latest notice available on request to any person. Silverado must provide its latest notice no later than the date of the first service delivery, including service delivered electronically, to an individual with a direct treatment relationship. In an emergency treatment situation, Silverado will provide the notice as soon as reasonably practicable after the emergency treatment situation.
Silverado will make a good faith effort to obtain a written acknowledgement of receipt of the notice, and if not obtained document our efforts and the reason why. Silverado will retain copies of the notices issues by our agency, and if applicable, any written acknowledgments or receipt of the notice or documentation of good faith efforts to obtain such written acknowledgement.
Silverado will have the notice available at its physical service delivery site (office) for individuals to request to take with them; post the notice in a clear and prominent location (office waiting room) where it is reasonable to expect individuals seeking services from Silverado to be able to read the notice; whenever the notice is revised, make the notice available upon request on or after the effective date of the revision and promptly comply with the aforementioned.
Silverado will prominently post and make available its notice on our website. Silverado may provide the notice to an individual by e-mail if the individual agrees and such agreement has not been withdrawn. If the first service delivery to an individual is electronically (ex. Telehealth), Silverado must provide electronic notice automatically and contemporaneously in response to the individuals first request for service. The individual who is the recipient of electronic notice retains the right to obtain a paper copy upon request.
Silverado Counseling Services, LLC and its clinicians, employees, staff and/or independent contractors are dedicated to meeting your behavioral health treatment needs and treating you with the respect and consideration you deserve.
To receive services regardless of your age*, race, color, ethnicity or national origin, religion, culture, language**, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression, veteran status.
To be treated with courtesy, respect, and consideration at all times and under all circumstances.
To have privacy (including visual and auditory privacy), safety, and security maintained.
To be informed about your current diagnosis and treatment.
To participate in your care and other decisions about your mental health services.
To make decisions, in collaboration with your clinician, to accept or refuse treatment as permitted by law, and to be informed of the consequences and risks of such refusals.
To be assessed and treated individually, effectively, and as promptly as possible.
To receive necessary information in words you understand, and if you wish, to have a designated representative involved. This may also include interpreter services and/or assistive devices.
To access information contained in your medical record in a timely fashion, and within the limits of the law.
To have your personal and medical information and records kept confidential.
To request an emergency contact be notified promptly when you are admitted to the hospital.
To have all persons who have contact with you clearly identified by name and function.
To be free from mental and physical abuse.
To not be secluded or restrained, except to prevent injury to yourself or others.
To have advanced directives (a living will, special power of attorney, or medical treatment plan) honored and followed as permitted by law.
To receive, upon request and in a timely manner, a copy of your itemized bill, an explanation of the bill, and assistance in filing insurance forms and arranging for financial payment options.
To be informed of agency policies that apply to you.
To request, at your expense, additional professional opinions about your care.
To keep personal possessions unless they pose a danger to yourself or others, or interfere with care.
To receive information on how to express a concern or complaint about your care or service.
*Silverado Counseling does not currently treat children under the age of 13.
**Silverado Counseling's current clinicians do not speak any additional languages. However, clients will be offered the use of an interpreter as appropriate.
To cooperate with all persons providing your care and treatment.
To respect the property, comfort, environment and privacy of other clients.
To try and understand and follow instructions concerning your treatment and ask questions if you need an explanation or do not understand.
To provide accurate and complete information regarding your behavioral health and medical history by answering all questions as truthfully and completely as you can.
To be responsible in your payment for treatment and to be cooperative and timely in providing insurance information.
To inform your clinician of any changes in your both your psychotropic and medical medications.
To inform your clinician of any changes in your health status.
To accept responsibility for consequences following a decision to refuse treatment or instructions.
To support mutual consideration and respect by maintaining civil language and conduct with clinicians and office staff.
Payment & Collection Policies
1. Payment in full is required at the time of service and is past due within thirty (30) days from the date of service. If payment in full is not made as required, then in addition to all other amounts that may be due the undersigned agrees to pay a collection fee of up to forty percent (40%) of the principal amount as provided by §12-1-11 of the Utah Code Annotated, and further agree to pay all other costs of collection (whether incurred by Silverado or its assigns) including but not limited to court costs, reasonable attorney fees, and interest (both pre- and post-judgment).
2. Any interest due hereunder shall be calculated at a rate equal to eighteen percent (18%) per annum and may, as determined by Silverado or its assigns: (a) accrue on some or all amounts due, (b) and compound as frequently as daily - meaning that accruing interest may be added to the balance owing as frequently as daily such that it shall thereafter constitute part of the amount upon which interest accrues during the next accrual period.
Silverado has contracted with Mountain Land Collections for collection services. They may be contacted at #801-492-0136 or PO Box 1280, American Fork, UT 84003.
The responsible party for payment hereby consent to:
1. being contacted by telephone at any phone number (including but not limited to wireless/cellular phone numbers) provided to Silverado by the responsible party or anyone associated with or acting on their behalf. I understand and agree that such calls may be initiated by Silverado or any of its affiliates, agents, contractors or assigns, including but not limited to billing companies and/or third-party collection agency(ies), and that the methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automated dialing device and/or the use of text messages - some or all of which may result in data charges.
2. receiving e-mails under the same terms at any e-mail address provided by the responsible party or anyone associated with or acting on their behalf.
3. In granting each and all of the foregoing permissions, I understand that I am responsible for ensuring my own level of privacy.