Notice of Privacy Practices
Notice of Privacy Practices – Short Version (Effective 03/01/2023)
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.
Notices and Statements
As a covered entity, Silverado Counseling Services, LLC and its associates (hereinafter referred to as “Silverado”, “We”, “Our”) is providing this “short version” notice (“long version” is available upon request) to advise individuals: (1) of the uses and disclosures of protected health information (“PHI”); (2) of their rights under the Health Insurance Portability and Accountability Act (“HIPAA”); (3) and our legal duties. Silverado must provide this notice in “plain language” and has attempted to do so.
(1) Uses and Disclosures
The following purposes describe different ways that we may use and/or disclose PHI. This is not a complete list nor does it include all of the ways Silverado is permitted to use and/or disclose PHI.
• We use PHI, either created by our agency or received from another provider through a disclosure, to support treatment or services we provide to an individual.
• We may disclose PHI with an individual’s consent or authorization. For example: An individual may sign a HIPAA compliant “release of information” for Silverado to disclose and submit records to another provider who is managing their medications.
• We may use and disclose PHI to bill and collect payment. For example: We may need to provide PHI such as diagnosis and the individual’s name on a Health Insurance Claim Form to seek reimbursement.
Health Care Operations
• We may use and disclose PHI about an individual that is necessary to run our internal agency operations. For example: Through our practice management software, we send text and/or email appointment reminders to individuals having a scheduled appointment.
Uses and/or Disclosures without the Individual’s Written Authorization
• Silverado is not subject to confidentiality if it is permitted or required by State or Federal law, rule, regulation, or order to report or disclose. For example: If an individual communicates an actual threat of physical violence against a potential victim we are compelled to take precautions to protect those involved. See Silverado’s “Notice of Exceptions to Confidentiality” for more information.
• Silverado may, in the exercise of professional judgment, disclose PHI deemed “medically necessary” if we believe it is in the best interests of the individual. For example: An individual has a behavioral health or medical emergency while at our office, we may provide PHI to emergency services that is pertinent to the immediate situation. We may then notify the individual’s emergency contact of the situation.
(2) Individual Rights
An individual has a right to adequate notice of the uses and/or disclosures of PHI that may be made by a covered entity (i.e., Silverado), and the individual’s rights and the covered entity’s legal duties with respect to PHI.
A) Request restrictions on certain uses and/or disclosures of PHI
You can ask us not to use or disclose certain PHI for treatment, payment, or our health care operations. However, please be advised that we are not required to agree to your request and may decline.
B) Receive confidential communication of PHI
You can ask us to contact you in a specific way (e.g., home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
C) Inspect and Copy PHI
You can ask to inspect or receive a copy of your medical record or other health information we have about you. We will provide a copy or a summary of PHI about you, usually within 30 days of your request, unless a limited basis for denying access applies. Please be advised that Psychotherapy notes are specifically excluded and other HIPAA sections do outline grounds for denial.
D) Amend PHI
You can ask us to correct information about you that you think is incorrect or incomplete. We may say “no” to your request but we’ll provide you an explanation. Even if we say “no” to your request, you have the right to submit a written addendum to your record and we’ll put it on file.
E) Receive an accounting of disclosures of PHI
You can request an accounting of the times we’ve shared your PHI, who we shared it with, and why it was shared. We will include all the disclosures except for those about treatment, payment, our health care operations, and certain other disclosures (e.g., any you asked us to make).
F) Obtain a copy of this notice
You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you a paper copy promptly.
(3) Silverado’s Duties
A) Silverado is required by law to maintain the privacy of PHI, provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI.
B) Silverado is required to abide by the terms of this notice currently in effect.
C) Silverado reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains, including PHI that we created or received prior to issuing a revised notice.
Contact or Complaints
If you have questions or would like additional information, please contact Silverado’s Administration at (801)983-5540. If you believe your privacy rights have been violated, you can file a written grievance with Silverado at the address below. An individual will not be retaliated against for filing a complaint.
Silverado Counseling Services, LLC
PO Box 521207
Salt Lake City, UT 84152
Alternatively, you may file a complaint with the U.S. Secretary of Health and Human Services.
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.