PRIVACY POLICY:

Morgan Hill Psychiatry, Inc.

Notice of Privacy Practices

This notice describes how your health information may be used, how it may be disclosed, your rights, and our obligations with respect to it. Any changes in this information will result in a revised document and will be posted on our website.

Where can we use or disclosure information about you?

With your consent:

1. To our billing services as needed for administrative reasons.
2. To other individuals or professionals involved in your evaluation or healthcare.
3. To the staff of your health plan or managed care organization (MCO) or other party financially responsible for your care for purposes of billing, trouble shooting claims, or other administrative reasons.

Without your consent:

1. In cases of suspected child or elder abuse, serious threat of suicide or homicide, or gravely disabling conditions.
2. Where required by law or a judge.
3. To a public health agency for purposes of controlling disease.
4. To health oversight agencies for regulatory, licensing, or other legal purposes.

What legal rights do you have regarding your information?

1. You may revoke any consent you sign with us for release of information.
2. You are not obligated to sign any consent or release, although we may not be able to treat you unless you release information to us, and your insurance company or MCO may not reimburse if information is not released to them.
3. You may request an accounting of all persons to whom we have disclosed information about you.
4. You may review our records of your information and request amendments if you believe inaccuracies exist. If you suspect inaccuracy and request amendment, we will discuss the issues with you and make changes if we agree. If we do not agree, you have the right to add a statement of disagreement to your record, and we have the right to add a statement of explanation.
5. You may request a copy of your record or any part of it. We are allowed to charge $0.91 per page for up to 30 pages and $0.69 per page thereafter, along with a clerical fee of $30.00.
6. If you believe we have violated your privacy rights, you may forward a written complaint to the U.S. Secretary of Health and Human Services. If you do file a complaint I am legally prohibited from retaliating against you.

I have read and agree to the above.

Signature _______________________________________________ Date__________________________

Signature of Parents/Legal Guardians in case of a minor__________________

Date:_____________________________________________________