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NOTICE OF PRIVACY PRACTICES POLICY

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.

If you have any questions or a complaint contact:

Larry Ekdahl at Caravel Autism Health, LLC
1575 Allouez Avenue
Green Bay, WI 54311
Phone: 844-583-5437
Fax: 844-834-8139

If you require additional information regarding any of these rights, please see a staff member Caravel Autism Health, LLC.

The Health Insurance Portability & Accountability Act of 1996, as amended (”HIPAA”), is a federal law that requires Covered Entities to (i) comply with the Rules’ requirements to protect the privacy and security of health information, and (ii) provide individuals with certain rights with respect to their health information. The Privacy Rule is intended to assure that an individual’s health information is properly protected while allowing the flow of health information needed to provide and promote high-quality care and to protect the public’s health and well-being. As required by HIPAA, the following explains how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

We may use and disclose your health information without your consent or authorization for each of the following purposes or reasons:

  • Pre-authorizations: Pre-authorizations means obtaining authorization from your insurance company(ies) to provide evaluation for services to potential clients.
  • Therapy: Therapy is providing, coordinating, or managing health care and related services by one or more health care providers.
  • Payment: Payment encompasses activities such as obtaining authorization and/or reimbursement for services, confirming coverage, billing or collection activities and utilization review.
  • Health Care Operations: Health care operations includes the business aspect of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, legal services, and customer service.

We may also disclose your personal health information without your consent or authorization for the following reasons:

  • When disclosure is required by federal, state, or local law (e.g., a court proceeding, for health oversight purposes, etc.)
  • In emergency situations and to prevent or mitigate a serious threat to the health or safety of a person or the public.
  • If there is a reasonable suspicion of abuse or neglect.
  • For public health purposes.
  • For specific government and medical research purposes.
  • For law enforcement purposes as required by law.
  • To Business Associates once they have agreed in writing to safeguard personal health information.

In addition, we may distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about therapy alternatives or other health-related benefits and services that may be of interest to you.

Other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

YOUR RIGHTS

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer of Caravel Autism Health, LLC, Larry Ekdahl, at the address above.

Your Rights:

  • The right to request restriction on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, closer personal friends, or any other person identified by you. We are, however, not required to agree to requested restriction.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to amend your protected health information.
  • The right to receive an accounting of certain disclosures of protected health information.
  • The right to obtain a paper or email copy of this notice from us upon request.
  • The right to request a restriction on disclosing your health information to a health plan or your insurance company when you pay for a health care service out-of-pocket in full, provided there are no other legal requirements for such disclosure.
  • The right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of October, 2009 and has been subsequently updated. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice effective for all protected health information that we maintain. You may request a written copy of the current Notice of Privacy Practices at any time.

COMPLAINTS

You have recourse if you feel that your privacy protections have been violated. You have the request to the Privacy Officer of Caravel Autism Health, LLC, Larry Ekdahl, at the address above, or with the Department of Health and Human Services, Office of Civil Rights. The Privacy Officer can provide you with the appropriate address upon request, or you may visit www.HHS.gov/OCR for further information. We will not retaliate against you for filing a complaint.