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. 

Samuel Christie, MT-BC (hereafter referred to as the “Practice” or "I") 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.
  • 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 will say “yes” 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:
Samuel Christie, MT-BC
114 Hunter Run Rd
Sam Christie
703-261-4983

  • You can 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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.
  • The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.

OUR USES AND DISCLOSURES OF PHI
1. Routine Uses and Disclosures of PHI
Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached Release of Information and/or general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

To treat you.
  • The Practice can use and share PHI with other professionals who are treating you with your consent as indicated on your Release of Information Form.
  • Example: Your primary care doctor asks about your music therapy treatments or other relevant treatment that are addressed in music therapy, and you have indicated via Release of Information Form and/or general consent form that the Practice can share PHI with this doctor.

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 assist you in billing and getting payment from health plans or other entities. Please note that this section is regarding release of PHI and is not indicative of insurance acceptance or financial agreements. Insurance and financial general policy are located within Practice Policies form under 'Financial Agreement'.
  • Example: The Practice gives PHI to your health insurance agent/point of contact so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object (Limits to Confidentiality)
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. If you wish to receive services from me, you must sign the attached form indicating that you understand and consent to accept my policies about confidentiality and its limits. We will discuss these issues at our first session if necessary, but you may reopen the conversation at any time during our work together.

The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

Emergency If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Virginia law to report the matter immediately to the Virginia Department of Social Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
· Health Oversight: By policy, the Practice reserves the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make a report to the licensing board. If you are yourself a health care provider, I am required by law to report to your licensing board if I believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records for investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so that you (or your attorney, or I ) can file a motion to block the subpoena and can give reasons why I think your records should be protected from disclosure However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. NOTE: In Virginia civil court cases, therapy information or records are not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue (e.g., if you sue someone for mental/emotional damages), or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: Under Virginia law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or law enforcement officer, whether you are a minor or an adult.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
· Records of Minors: Virginia has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if you are signing as a Parent or Guardian on behalf of a minor. You will be asked to sign a separate adolescent privacy form if you are signing on behalf of a child who is 13 and older.
 
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care.

If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice will never market or sell your personal information to a third party

The Practice will use and share PHI with other professionals who are treating you upon your request and with your consent as indicated on a Release of Information Form. You will be asked to sign this in order for the Practice to speak with other providers (such as your doctor, a primary therapist, or a speech language pathologist) about your care.
  • Example: Your primary care doctor asks about your music therapy treatments or other relevant treatment that are addressed in music therapy, and you have indicated via Release of Information Form that the Practice can share PHI with this doctor.

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.

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 the website http://createmusictherapy.com/notice-of-privacy-practices.
• The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on 5/23/22.

I acknowledge my receipt of this Notice of Privacy Practices for Samuel Christie, MT-BC and agree to all policies within in regards to myself, or on behalf of a minor for whom I am a parent or guardian. 

We have or will discuss these policies if necessary, and I understand that I may ask questions about them at any time in the future.

I consent to accept these policies as a condition of receiving music therapy services for myself, or on behalf of a minor for whom I am a parent or guardian.