Notice of Privacy Practices
HALCYON INFUSIONS & THERAPEUTICS, PLLC
1611 12th Ave Rd Suite A
Nampa, ID 83686
Effective Date of this Notice: 06/01/26
Health Insurance Portability Accountability Act (HIPAA)
This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.
I am also required by law to provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2.
The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communication between a patient and a provider. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
-
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
-
For my use in treating you.
-
For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
-
For my use in defending myself in legal proceedings instituted by you.
-
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
-
Required by law and the use or disclosure is limited to the requirements of such law.
-
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
-
Required by a coroner who is performing duties authorized by law.
-
Required to help avert a serious threat to the health and safety of others.
-
-
Substance Use Disorder (SUD) Counseling Notes. I may also maintain “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that I have already acted upon it to disclose these notes in accordance with your initial authorization.
-
Marketing Purposes. As a mental health professional, I will not use or disclose your PHI for marketing purposes.
-
Sale of PHI. As a mental health professional, I will not sell your PHI in the regular course of my business.
CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION:
There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without authorization:
● When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
● For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
● For health oversight activities, including audits and investigations. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.
● For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
● If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. However, for records protected by 42 C.F.R. Part 2, such records or testimony relaying their content shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
● If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
● For law enforcement purposes, including reporting crimes occurring on my premises.
● To coroners or medical examiners, when such individuals are performing duties authorized by law.
● Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.
● For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
● For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
● Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
● I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:
● If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Idaho Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
● If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Idaho Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
● If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:
● Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
● Fundraising. If I intend to use or disclose your records protected by 42 C.F.R. Part 2 for fundraising for my benefit, I will provide you with a clear and conspicuous opportunity to opt-out before any such use or disclosure occurs.
PATIENT RIGHTS AND PROVIDER DUTIES
Use and Disclosure of Protected Health Information:
● For Treatment – I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will request you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Informed Consent Agreement.
● For Operations – I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.
● Lawsuits and Disputes - If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. However, for records protected by 42 C.F.R. Part 2, such records or testimony relaying their content shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures permitted by HIPAA for treatment, payment, and health care operations are materially limited by the stricter standards of those regulations. Furthermore, information disclosed pursuant to these rules may be subject to redisclosure by the recipient and may no longer be protected by federal privacy standards.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Patient's Rights:
● Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
● The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. You also have the right to request an accounting of disclosures specifically for your substance use disorder records protected under 42 C.F.R. Part 2.
● Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
● Right to Inspect and Copy – Other than “psychotherapy notes” and “SUD counseling notes” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for doing so. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
● Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.
● Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.
Provider’s Duties:
● I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. 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 terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice.
COMPLAINTS
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, the State of Idaho Department of Health, or the Secretary of the U.S. Department of Health and Human Services.
Acknowledgement of Receipt of Privacy Notice