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Please read this notice carefully. HIPAA describes how medical information about you is protected, and circumstances under which your protected health information (PHI) may be disclosed. PHI includes any identifiable information about your physical or mental health, the health care you receive, and the payment for your health care. Information about care that you received from other providers may also be included in your PHI.

Date: 08/01/2021

How SPS may Use and Disclosure Your PHI:

Except for the purposes described below, your health information may only be used or disclosed with your written permission. You may revoke such permission at any time by giving SPS a written request. In a limited number of circumstances, however, health information can be used and disclosed without your consent or authorization. Some of these conditions are directly related to your treatment, others are required by law. These include:

  1.  For Treatment - PHI may be disclosed to doctors, nurses, residents or students and other health care providers that are involved in delivering your health care and related services. PHI may be disclosed to other health care professionals for coordination of your care. PHI may also be  disclosed to health care providers for the purposes of referring you for specialised services. PHI may be used by our support staff to communicate your questions or concerns with your clinical team,  provide follow up appointments or instructions or to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you. 

  2. For health care operations: Disclosure of your health information may be made to your health care service plan (most often, your health insurer) or to health care providers contracting with your plan for its administration, such as case managers and care coordinators.

  3. For Payment: Health information can be disclosed to bill and collect payment for treatment and services. For instance, this information may be disclosed to your health insurer to obtain reimbursement for care provided or to determine eligibility or coverage.

  4. Other health-related disclosures: Health information may also be disclosed to others without your consent in certain emergencies. Your consent is not required if you are at imminent risk for harm to self or others or otherwise need emergency medical or psychiatric treatment 

  5. Appointment Reminders - PHI may be used/ disclosed to remind you of scheduled appointments, or that it is time to make a routine appointment.  We may also call or write to notify you of other treatments or services available at our office that might help you.  Unless you tell us otherwise, we may mail or email you an appointment reminder, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

  6. Business Associates - PHI may be used/disclosed to contractors, agents and other business associates who need the information to assist SPS with obtaining payment or carrying out its business operations. If SPS discloses your PHI to a business associate, SPS  will have a written contract with that business associate to ensure that it also protects your PHI.

  7. Family or primary care-giver:  In limited circumstances and if you agree/ do not object, PHI may be disclosed to  persons involved in your care or payment for your care if directly related to their involvement in your care or payment for your care.

  8. Required by Law - PHI may be disclosed/used as required by law, such as to report a felony committed on its premises; pursuant to a court order; to report abuse or neglect, and other situations where SPS is required to make reports and/or disclose PHI pursuant to a statute or regulation

  9. Workers’ Compensation:If you file a worker’s compensation claim, your provider must furnish your employer with a report that incorporates the provider’s findings about your injury and treatment within five working days of the date of the initial examination, and at subsequent intervals as may be required by the administrative director of the Workers’ Compensation Commission, in order to determine your eligibility for worker’s compensation.

  10.  Judicial or Administrative Proceedings:If you are involved in a court proceeding and a request is made about the professional services that a provider has provided you, the provider must not release your information without (a) your written authorization or the authorization of your attorney or personal representative; (b) a court order; or (c) a subpoena duces tecum (a subpoena to provide records). In the last instance, the party seeking your records must provide the provider with a showing that you or your attorney has been served with a copy of the subpoena, affidavit, and the appropriate notice. In addition, you must not have notified the provider that you are bringing a motion in the to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case

  11. Health Oversight:If a complaint is filed against a provider with a Massachusetts Professional Board, the Board has the authority to subpoena confidential health information from the provider relevant to that complaint.

  12. Lawsuits and Disputes - If you bring a legal action or other proceeding against SPS or our employees or agents, we may use and disclose PHI to defend ourselves.

  13. In the unfortunate event of your death- we may disclose your PHI to coroners, medical examiners, funeral directors, and certain organ and tissue procurement organizations

Uses/Disclosures Requiring Written Authorization

SPS is required to have a written authorization from you or your legally authorized personal representative for uses/disclosures beyond treatment, payment, and health care operations, unless an exception listed above applies. You may cancel an authorization at any time, if you do so in writing. A cancellation will stop future uses/disclosures except to the extent SPS  has already acted based upon your authorization. Authorization is required for most uses and disclosures of psychotherapy notes (these are the notes that certain professional behavioral health providers maintain that record your appointments with them and are not stored in your medical record), certain substance use disorder information, HIV testing or test results, and certain genetic information even if disclosure is being made for treatment, payment, or health care operations purposes as described above.

Your Rights Concerning Your PHI

You or your legally authorized personal representative has the right to: 

  1. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and review confidential communications of health information by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a provider. Upon your request, SPS can send your bill to another address.

  2. Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of your health information and the health and billing records used to make decisions about you for as long as the health information is maintained in the record. Your access may be denied under certain circumstances. In some cases, you may have a denial reviewed. If you request, your provider will discuss with you the details of the request and denial process. Fees may be charged for copying and mailing. Ordinarily, SPS will respond to your request within 30 days. If additional time is needed to respond, SPS will notify you within the 30 days to explain the reason(s) for the delay and indicate when you can expect a final answer to your request. This request must be made in writing. 

  3.  Right to request to make amendments to your PHI.You have the right to request to amend your health information for as long as the health information is maintained in the record. In some circumstances your request may be denied. If you request, your provider will discuss with you the details of the amendment process. .

  4. Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information. However, providers are not required to agree to the restrictions you request.

  5. Right to an Accounting: You generally have the right to receive an accounting of disclosures of health information for which you have provided neither consent nor authorization, as in the situations described above. If you request, your provider will discuss with you the details of the accounting process.

  6. Right to a Paper Copy: You have the right to obtain a paper copy of this notice, even if you have agreed to receive it electronically.

Record Retention

Your individual records will be retained a minimum of 6 years from the last date you receive services from us. After that time, your records may be destroyed.

 Breach of PHI 

SPS will inform you if a breach of your unsecured PHI occurs.


 If you believe that your privacy or privacy rights have been violated, or you want to file a complaint, you may contact: SPS Privacy Officer at Suburban Psychiatric Specialists, PC Address: 1500 Providence Highway, Unit#22 Norwood, MA 02062.  You also may file a complaint with the Secretary of Health and Human Services, Office for Civil Rights, U.S. Department of Health and Human Services, JFK Federal Building, Room 1875, Boston, MA. 02203. The complaint must be in writing, describe the acts or omissions that you believe violate your privacy rights, and be filed within 180 days of when you knew or should have known that the act or omission occurred. No one may retaliate against you for filing a complaint or for exercising your rights as described in this notice. 

Changes to this Notice

SPS may change its privacy practices and the terms of this notice at any time. Changes will apply to PHI that SPS already has as well as PHI that SPS receives in the future. The most current  notice will be prominently posted in the office where registration occurs. The notice will also  be maintained on the organization’s Web site (if applicable Web site exists) for downloading. You will be provided a hard copy upon request.

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