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.

Polli Psychology, PLLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice’s legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee for administrative duties.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person’s life. You may have a right to have this decision reviewed.

To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice plans to agree to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated.
• You can file a complaint by contacting the Practice using the following information:

Polli Psychology, PLLC
12 South Street, Suite 2C
Hanover, NH 03755
Phone: 603-691-6594

• You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also send a written complaint to the New Hampshire Secretary of State Office of Professional Regulation, 121 South Fruit Street, Concord, NH 03301. 

• The Practice will not retaliate against you for filing a complaint.

OUR USES AND DISCLOSURES

1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice may disclose your PHI to your healthcare service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.

We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment and payment operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. 

You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation or modification is not effective until we receive it.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object

The Practice may use or disclose PHI without your authorization or an opportunity for you to object in the following instances:

To help with public health and safety issues.
• Serious threat to health or safety: To prevent a serious and imminent threat including a threat to self-harm or a threat to someone’s property. If a client communicates a serious risk of danger to themselves or an identifiable victim or their property, we have a mandated duty to take protective actions, including notifying the potential victim and contacting the police. We may also seek hospitalization of the client or contact others who can assist in protecting the client or the victim.

• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.

• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. If a complaint is filed against us with the New Hampshire Secretary of State Office of Professional Regulation (“OPR”), the OPR has the authority to subpoena confidential mental health information from us relevant to that complaint. 

• To report child abuse. If we have reasonable cause to believe that a child under 16 has been the victim of child abuse or neglect, the law requires that a provider file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information.

• To report elder abuse or abuse of a dependent adult. If we have reasonable cause to believe the abuse, neglect, or financial exploitation of a vulnerable adult, the law requires that a therapist file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. 

To comply with law, law enforcement, government or other requests.
• Required by law: If required by federal, state or local law.

• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request. If there is a court order requiring the disclosure of information, then we will have to provide information in accordance with the court order. If, as part of a court proceeding, we are served with a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides us a showing that you or your attorney have been served with the subpoena, affidavit and the appropriate notice, and you have not notified us that you are bringing a motion to block or modify the subpoena, then we will produce the request records.

• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.

• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.

• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.

• Workers’ Compensation: To comply with workers’ compensation laws or support claims.

• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Written Authorization or Opportunity to Object

The Practice may disclose PHI to:
• Your family, friends, healthcare professionals, or others, if PHI directly relates to that person’s involvement in your care if you have signed a release of information (“ROI”).
• If it is in your best interest because you are unable to state your preference.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

We never market or sell your personal information.

OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on your Therapy Notes portal or by reviewing the Practice’s Privacy Policy at the bottom of the website at http://www.pollipsychology.com.
• The Practice will inform you if PHI is compromised in a breach.

“Polli Psychology, PLLC” SMS Text Messaging Terms of Service

These SMS Text Messaging Terms of Service (these “SMS Terms”) are incorporated into all agreements between you and “Polli Psychology, PLLC” (“our organization”, “us”, “we”), including any agreements that are preexisting and any agreements that might be enacted contemporaneously with these SMS Terms.

“Polli Psychology, PLLC” might use SMS text messaging, from time to time, for certain types of communication with you, including potentially for administrative issues, such as billing, or for health-related issues, such as care reminders.

You agree to receive (you “opt in” to receiving) SMS text messages from “Polli Psychology, PLLC” , related to services that we are providing to you. Message and data rates may apply, and message frequency varies. You may text us STOP at any time to opt out of receiving SMS text messages from us. You may text us HELP at any time to receive help.

SMS text messages from “Polli Psychology, PLLC” may originate from our organizational phone numbers, including:

(603) 691-6594

There may be terms in other agreements between you and us that also apply to our organization’s use of SMS text messaging, such as general terms related to privacy and data handling for our organization that are not specific to SMS text messaging. You agree that you have reviewed all agreements that we have provided you.