Hippa Policy

919 South 7th Street, Suite 401 Bismarck, ND 58504

Phone: (701) 751-1579; Fax (701) 401-0115

Your Provider at Wildflower Mental Health, PLLC is an independent practitioner practicing within their scope of expertise and training within this practice. Any Provider affiliated with Wildflower Mental Health, PLLC is required to adhere to the privacy practices as indicated in this Notice.

HIPAA Notice of Privacy Practices

 Effective Date: January 1, 2024

This Notice is available on Practice website: www.wildflowermhnd.com, with your electronic new patient forms, or written copy. If you require an additional paper copy of this request one may be provided to you by your provider.

Please note that this notice is required by Federal law, and the information it contains is mandated by law. If you have any questions about how your Protected Health Information (PHI) is used, please contact Wildflower Mental Health, PLLC at 701-751-1579.

NOTICE OF PRIVACY PRACTICES

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.

Wildflower Mental Health, PLLC is required by law to maintain the privacy and security of your protected health information (hereinafter, “PHI”) and to provide you with this Notice of Privacy Practices (hereinafter, “Notice”). Wildflower Mental Health, PLLC and all independent practitioners (hereinafter, “Providers”) providing mental health services within the practice must abide by the terms of this Notice, and Wildflower Mental Health, PLLC must notify you if a breach of your PHI occurs.

Wildflower Mental Health, PLLC reserves the right to change the terms of this Notice, and such changes will apply to all information within your PHI. The most recent version of this Notice will appear on Wildflower Mental Health’s website within one business week of any changes. You may request a paper copy from your Provider.

Except for the specific purposes set forth below, Wildflower Mental Health, PLLC and/or your Providers will use and disclose your PHI only with your written Authorization. You reserve the right to revoke such Authorization at any time. In order to revoke an Authorization, please send a written request to Amanda Kouba, LCSW at the office address indicated at the beginning of this Notice.

Uses Inside Practice and Disclosures Outside Practice Relating to Treatment, Payment, or Health Care Operations DO NOT require your written Authorization.

Please refer to Wildflower Mental Health, PLLC Consent, Policies and Agreement. You may request your original signed copy obtained at the commencement of your care. Wildflower Mental Health, PLLC and/or your Providers can use and disclose your PHI without your Authorization for the following reasons:

  1. For your treatment. Wildflower Mental Health, PLLC and/or your Providers can use and disclose your PHI to provide treatment to you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, we can disclose your PHI to him/her to help coordinate your care, although Wildflower Mental Health, PLLC prefers for you to give Authorization to do so.
  2. To obtain payment for your treatment. Wildflower Mental Health, PLLC can use and disclose your PHI to bill and collect payment for the treatment and services provided by the Providers to you. For example, If you choose to use your insurance benefits for mental health services, we can send your PHI to your insurance company in order to obtain payment for the health care services that have been provided to you.
  3. For health care operations. Wildflower Mental Health, PLLC and/or your Providers can use and disclose your PHI for purposes of conducting operations pertaining to Wildflower Mental Health, PLLC and your Providers’ practice, including contacting you when necessary. For example, Wildflower Mental Health, PLLC and/or Providers may need to disclose your PHI to Wildflower Mental Health, PLLC’s and/or Providers’ attorneys to obtain advice about complying with applicable laws.

Certain Uses and Disclosures Require Your Authorization.

  1. Psychotherapy Notes. HIPAA defines Psychotherapy Notes as follows: “Notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.” Psychotherapy notes are treated differently from other protected health information because they contain the Providers’ personal notes and often include sensitive information of the type that is not normally needed for the patient’s “treatment, payment, or health care operations” as defined by HIPAA.

Providers providing care at Wildflower Mental Health, PLLC are not required to keep psychotherapy notes. If your Providers keep psychotherapy notes they are not stored with your PHI nor does Wildflower Mental Health, PLLC have access to such notes.

Wildflower Mental Health, PLLC and the Providers are required to document your treatment and keep a record of this documentation. The treatment record will include:

  • Any summary of the following items: diagnosis, functional status, treatment plan with goals, symptoms, prognosis, treatment progress to date, discharge summary
  • Medication management information provided by you
  • Counseling session start and stop times
  • Modalities and frequencies of treatment furnished
  • Results of clinical tests, assessments, or inventories

Wildflower Mental Health, PLLC keeps a record of your PHI and treatment records in its office; your Providers are responsible for the creation, update, and maintenance of your record. All records are maintained in a secure location with restricted access. You may request a copy of your treatment records or request a brief summary of your treatment to date at any time. There may be a reasonable, cost-based fee for copying records and/or providing a summary.

  1. Marketing Purposes. Wildflower Mental Health, PLLC and your Providers will not use or disclose your PHI for marketing purposes. Marketing is defined as: financial remuneration for communicating about other businesses’ health-related services or products to patients.
  2. Sale of PHI. Wildflower Mental Health, PLLC and your Providers will not sell your PHI in the regular course of business.

Certain Uses and Disclosures Do Not Require Your Authorization. (Subject to certain limitations)          As mandated by law, Wildflower Mental Health, PLLC and your Providers can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
  3. For health oversight activities, including audits and investigations.
  4. For judicial and administrative proceedings, including responding to a court or administrative order, although preference is to obtain Authorization from you before doing so.
  5. For law enforcement purposes, including reporting crimes occurring on the premises.
  6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
  9. For workers’ compensation purposes. Although the preference is an Authorization from you, Wildflower Mental Health, PLLC and your Providers may provide your PHI to comply with workers’ compensation laws.
  10. Appointment reminders and health related benefits or services. Wildflower Mental Health, PLLC and/or your Providers may use and disclose your PHI to contact you to remind you that you have an appointment. Wildflower Mental Health, PLLC and/or your Providers may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that Wildflower Mental Health, PLLC may offer.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

  1. Disclosures to family, friends, or others. Wildflower Mental Health, PLLC and/or your Providers may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part, in writing. The opportunity to consent may be obtained retroactively in emergency situations.

Your Rights Regarding your (“PHI”)

 You have the following rights with respect to your PHI:

  1. The Right to Request Limits on Uses and Disclosures of Your (“PHI”). You have the right to ask Wildflower Mental Health, PLLC and/or your Providers not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Wildflower Mental Health, PLLC and/or your Providers are not required to agree to your request, and Wildflower Mental Health, PLLC and/or your Providers may say “no” if it is believed such a request would affect your health care.
  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
  3. The Right to Choose How Wildflower Mental Health, PLLC and your Providers Send PHI to You. You have the right to ask Wildflower Mental Health, PLLC and your Providers to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and Wildflower Mental Health, PLLC and your Providers will agree to all reasonable requests. Please note: Information specific to clinical matters – treatment, diagnosis, behavior/school functioning, etc. will not be shared via email.
  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that Wildflower Mental Health, PLLC has about you. Wildflower Mental Health, PLLC will provide you with a copy of your record, or a summary of it prepared by your Providers, if you agree to receive a summary, within 30 days of receiving your written request, and Wildflower Mental Health, PLLC may charge a cost-based fee for doing so.
  5. The Right to Get a List of the Disclosures Made by Wildflower Mental Health, PLLC and/or your Providers. You have the right to request a list of instances in which Wildflower Mental Health, PLLC and/or your Providers disclosed your PHI for purposes other than treatment, payment, health care operations, or for which you provided Authorization. Wildflower Mental Health, PLLC will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include disclosures made in the last six years unless you request a shorter time. This list will be provided to you at no charge.
  6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that Wildflower Mental Health, PLLC and/or your Providers correct the existing information or add the missing information. If Wildflower Mental Health, PLLC and/or your Providers deny your request, a written explanation for the denial will be provided to you within 60 days of receiving your request.
  7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this Notice by e-mail. Even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

How to file a complaint about Privacy Practices

If you think Wildflower Mental Health, PLLC and/or your Provider may have violated your privacy rights, you may file a complaint with Wildflower Mental Health, PLLC. The address and telephone number are at the beginning of this document. Wildflower Mental Health, PLLC may contact you per your request to discuss your complaint.

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

  1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
  2. Calling 1-877-696-6775; or,
  3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

Wildflower Mental Health, PLLC and/your (“Provider”) will not retaliate against you if you file a complaint about an issue pertaining to privacy practices.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Phone

701-751-1579

Fax

701-401-0115

Address

919 South 7th Street, Suite 401
Bismarck ND 58504

Hours

Monday through Friday- By Appointment Only