I understand that therapy conducted online is technical in nature and that problems may occur with internet connectivity. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction). Any problems with internet availability or connectivity are outside the control of the Dr. Paula Nelson and Dr. Paula Nelson makes no guarantee that such services will be available. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via telephone, a new appointment will be re-scheduled. Please note, however, that if a session is disrupted for technical reasons, Dr. Paula Nelson, at her sole discretion, may resume the session by telephone. All disrupted sessions over 15 minutes, but less than the full session time will be charged to you at a prorated amount. Please note that Dr. Paula Nelson has a 24-hour cancellation policy. Should you miss or cancel an appointment within the 24-hour window, you will be charged for the session.


Additionally, although Dr. Paula Nelson has taken substantial steps to ensure the confidentiality and privacy of therapy provided online, Dr. Paula Nelson cannot guarantee the security of any internet transmissions or communications. I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. I agree to release and indemnify Dr. Paula Nelson from all suits, claims, and other actions originating from any services provided by Dr. Paula Nelson.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW THIS NOTICE CAREFULLY

Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices (“Notice”) is provided to you as a requirement of the Health Insurance Portability and Accountability Act (“HIPAA”). It describes how Dr. Paula Nelson may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This Notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our practice except when the release is required or authorized by law or regulation.

Dr. Paula Nelson is required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

Following are examples of permitted uses and disclosures of your protected health information. These examples are not exhaustive.

Required Uses and Disclosures. By law, Dr. Paula Nelson must disclose your health information to you unless it has been determined by a competent medical authority that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Health and Human Services (DHHS) for investigations or determinations of our compliance with laws on the protection of your health information.

Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

Payment. We may use or disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

The following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.

Abuse and Neglect Judicial and Administrative Proceedings
Emergencies Law Enforcement
National Security Public Safety (Duty to Warn)


• Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as state licensing boards or health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding your personal PHI maintained by our office. To exercise any of these rights, please submit your request in writing to Dr. Paula Nelson at paula@drpaulanelson.com.

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.

Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.
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Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
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Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
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Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
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Right to a Copy of this Notice. You have the right to a copy of this Notice.

ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE

You will be asked to provide a signed acknowledgment of receipt of this Notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing to Dr. Paula Nelson at paula@drpaulanelson.com with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201. We will not retaliate against you for filing a complaint.