Dr. Vaughn Tsoutsouris, PLLC
NOTICE OF PRIVACY PRACTICES: ARIZONA NOTICE FORM
- Uses and Disclosures for Treatment, Payment, and Health Care Operations
You may revoke all such authorizations of PHI or Psychotherapy Notes at any time provided each revocation is in writing. You may not revoke an authorization to the extent that 1) I have relied on that authorization; 2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
I will also obtain an authorization from you before using or disclosing:
- PHI: refers to information in your health record that could identify you- Treatment, Payment and Health Care Operations: Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and case coordination. I may also disclose your PHI to third-party business associates who perform certain activities for me (e.g. billing services)- Use: Activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you- Disclosure: Activities outside of my office such as releasing, transferring, or providing access to information about you to other parties
Right to be Notified if there is a Breach of Your Unsecured PHI. You have the right to be notified if: 1) there is a breach (a use of disclosure of your PHI in violation of HIPPA Privacy rule) involving your PHI; 2) that PHI has not been encrypted to government standards; and 3) my risk assessment fails to determine that there is a low probability your PHI has been compromised.
I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the current terms in effect.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at the address listed in the letterhead of this notice. You may also sent a written complaint to: Office of the Secretary, U.S. Department and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201.