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.
Effective date: set when adopted
Our responsibilities
LouCouPsych (sam md nova llc) is required by law to protect the privacy of your health information, to give you this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. We will tell you promptly if a breach occurs that may have compromised the privacy or security of your information.
We may change this notice. Changes will apply to all information we hold about you. The current notice is always available on our website, in our office, and on request.
How we use and share your information
We may use and share your health information without your written authorization for the following purposes.
Treatment
To provide and coordinate your care. For example, your psychiatrist and therapist at LouCouPsych may share information to plan your treatment, we may send prescriptions to your pharmacy, and we may talk with other clinicians who treat you.
Payment
To bill and collect payment for your care. Because we are an out-of-network practice, this usually means billing you directly and preparing a superbill that you choose to send to your insurer.
Health care operations
To run our practice, improve care, train staff, and meet legal and professional requirements.
Appointment reminders and messages
To contact you about appointments, refills, and your care by text, phone, email, or secure message.
Business associates
We work with companies that help us run the practice, such as our electronic health record (SimplePractice) and patient messaging service (Klara). They must sign agreements to protect your information.
Other uses and disclosures allowed or required by law
- As required by law, including federal, state, or local law.
- Serious threat to health or safety. To prevent or lessen a serious and imminent threat to you or others, as permitted by Virginia law.
- Abuse or neglect. To report suspected abuse or neglect of a child or vulnerable adult to the proper authorities.
- Prescription Monitoring Program. We check and report controlled-substance prescriptions through the Virginia Prescription Monitoring Program as the law requires.
- Public health and health oversight, such as reporting to public health authorities and cooperating with audits, licensing, and investigations.
- Legal proceedings, in response to a court order, or a subpoena that meets legal requirements.
- Law enforcement, in limited circumstances the law allows.
- Coroners and medical examiners, and for workers' compensation claims as the law allows.
- Specialized government functions, such as military or national security purposes, when the law requires.
- Family and others involved in your care. We may share information with a family member or friend involved in your care if you agree, if you don't object when given the chance, or in an emergency when we believe it is in your best interest.
Uses that need your written permission
We will not do the following without your written authorization:
- Share psychotherapy notes, except in the limited cases the law allows
- Use or share your information for marketing
- Sell your information
- Any other use or disclosure not described in this notice
You may revoke an authorization in writing at any time. Revoking won't affect anything we already did based on it.
Substance use disorder records
If you receive substance use disorder treatment from us, or we receive such records from another program, those records have extra protection under federal law (42 CFR Part 2).
- You may give a single written consent that lets us use and share these records for treatment, payment, and health care operations. You may revoke that consent in writing at any time.
- Anyone who receives your records with your consent may not re-disclose them except as the law allows.
- Your substance use disorder records, or testimony about them, cannot be used in any civil, criminal, administrative, or legislative proceeding against you unless you give specific written consent or a court issues an order that meets Part 2 requirements.
- We do not use your records for fundraising. If we ever did, you would have the right to opt out.
Your rights
See and get a copy of your records
You can ask to see or get an electronic or paper copy of your health information. We will respond within 30 days and may charge a reasonable, cost-based fee.
Ask us to correct your records
You can ask us to correct information you believe is wrong or incomplete. We may say no, but we'll tell you why in writing within 60 days.
Ask for confidential communications
You can ask us to contact you in a specific way, such as a different phone number or address. We will say yes to all reasonable requests.
Ask us to limit what we share
You can ask us not to use or share certain information. We are not required to agree, except in one case: if you pay for a service in full out of pocket and ask us not to share that information with your health plan, we will agree unless the law requires us to share it.
Get a list of disclosures
You can ask for a list of the times we shared your information in the six years before your request, with whom, and why. This list does not include treatment, payment, operations, and certain other disclosures. One list per year is free.
Get a copy of this notice
You can ask for a paper copy at any time, even if you agreed to get it electronically.
Choose someone to act for you
A legal guardian or someone with your medical power of attorney can exercise your rights. Virginia law may give minors control over certain mental health and substance use treatment records.
Complaints
If you believe your privacy rights were violated, you can file a complaint with our Privacy Officer, using the contact details on this page. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at hhs.gov/ocr/complaints or 1-800-368-1019. We will not retaliate against you for filing a complaint.