HIPAA Privacy Statement Url HIPAA Compliance Statement THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BEFORE SIGNING. Understanding Your Health Information When you begin working with Wonderment Therapies PLLC a record of treatment is made. Typically, this record contains your history, assessment, medical information, diagnoses, treatment, a plan for future treatment, etc. This information often referred to as you/your child's clinical record, serves as: 1. Basis for planning your care and treatment. 2. Legal document describing the care you received. 3. Means by which you or a third-party payer can verify that services billed were provided 4. A source of data for health officials charged with improving the health of the nation or needed services for the area. 5. A tool by which future or continual services can be approved. 6. Understanding what is in this record will help you to ensure its accuracy, better understand who, what, when and why others may access you information and help to make more informed decisions when authorizing disclosure to others. Your Health Information Rights Although your health record is the physical property of Wonderment Therapies PLLC the information belongs to you. You have the following rights: A. Right to Request a Restriction You have the right to request a restriction on our use and sharing of you protected health information. Wonderment Therapies PLLC can deny the request if it is unreasonable or would be detrimental to your treatment. B. Right to a Paper Copy of this Notice You have a right to obtain a paper copy of this notice. C. Right to Amend Your Health Information You have the right to request an amendment to the health information we maintain about you if you feel it is incorrect or incomplete for as long as the information is kept by Wonderment Therapies PLLC. To request an amendment, you must submit a request in writing and state the reason that supports your request. The disputed information will remain in the record along with the amended information. Wonderment Therapies PLLC may deny your request if the request is not submitted in writing, does not contain a reason to support the request, the information that is being questioned was not originated by Wonderment Therapies PLLC, it is not part of the information which you are permitted to inspect or copy, or it is currently accurate and complete. Health Care Insurance Providers If we do not file your insurance claims at this time, we will provide you with statements that you may submit to your insurance carrier or complete any forms as required by your insurance carrier in order to obtain reimbursement for out-of-network providers. In order to assist you with obtaining reimbursement for our services, your insurance carrier may require that we provide a clinical diagnosis, or additional clinical information such as treatment plans or summaries, or copies of your child’s entire clinical record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Although all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. We will provide you with a copy of any report or form that we submit upon your request. By signing this Notice, you agree that we can provide requested information to your carrier for authorization of services and if/when you choose to file a claim for any services that we have provided to you or your child. Others We May Share Your Information With As required by law we will disclose you/your child's protected health information, even if you do not sign an authorization form, under the following circumstances: 1. Public Health Activities-such as: reporting to a public health or government authority for preventing or controlling disease, injury, or reporting child abuse or neglect. 2. For certain purposes involving workplace illnesses or injuries. 3. Reporting victims of abuse, neglect or domestic violence-information will be disclosed as required by law. 4. Judicial and Administrative proceedings-information may be disclosed in response to a court or administrative order, subpoena, discovery requests, or other lawful process. Efforts will be made to notify you about the request or to obtain an order or agreement protecting the information. 5. Health oversight activities-information may be disclosed to a health oversight agency for activities authorized by law, such as, audits, inspections, investigations, licensure actions or other legal proceedings. 6. Research-only under your specific disclosure. 7. Workers Compensation. 8. Law Enforcement-as required by law to comply with reporting requirements including, but not limited to: complying with court orders, warrants, subpoenas, summons, identifying or locating a fugitive, missing person or material witness, when information is requested about the victim of a crime if the individual agrees, to report information about a suspicious death, to provide information about criminal conduct occurring at the agency, or information about emergency circumstances about a crime. Records We will review all testing results during our meetings with parents/guardians and offer you opportunities to review raw testing data with us. You will receive a written report that summarizes our findings. This report will include a summary and interpretation of all individual testing, as well as impressions from individual observations and consultations conducted as a part of a comprehensive, individual evaluation. Upon your request, we are happy to provide you with a written summary of our impressions from other meetings, consultations, or observations as well. We will forward copies of any reports or written summaries to others only with specific, written consent from you. Because of the proprietary nature of testing materials, we will release raw testing data only to other appropriately credentialed professionals (except as otherwise required by law). Legal Proceedings If you are involved in a court proceeding and a request is made for information concerning our professional services, we cannot provide any information without your written authorization or a court order. However, a court order may force us to reveal information. In that case, we will reveal only the minimally acceptable amount of information. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. Also, if a client files a complaint or lawsuit against anyone affiliated with Wonderment Therapies PLLC, we may disclose any and all relevant information regarding that client we deem necessary in order to defend ourselves. Confidentiality, Records, and Release of Information Occupational Therapy and Speech Therapy services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by Wonderment Therapies PLLC and Federal law and our professional codes of conduct/ethics. These exceptions are discussed below. To Protect the Client or Others from Harm If we have reason to suspect that a minor, elderly, or person with a disability is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include but not limited to, notifying the police or an intended victim, a minor’s parents, or others who could provide protection, or seek appropriate hospitalization. Professional Consultations Occupational Therapists and Speech Therapists will routinely consult about cases with other professionals. Therefore, we make every effort to avoid revealing the identity of our clients and any consulting professionals are also required to refrain from disclosing any information we reveal to them. If you want us to talk with or release specific information to other professionals with whom you are working, you will first need to sign an Authorization that specifies what information can be released and with whom it can be shared. Your Authorization is Required for Other Uses of Protected Health Information Wonderment Therapies PLLC will use and disclose protected health information (other than described in this Notice or required by law) only with your written authorization. You may revoke your authorization to use or disclose protected health information in writing, at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization except where we have already relied on the authorization. Our Responsibility Regarding You/Your Child’s Protected Health Information Wonderment Therapies PLLC is required by law to: 1. Maintain the privacy of your health information. 2. Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. 3. Abide by the terms of this notice. 4. Notify you if we are unable to agree to a requested restriction. 5. Inform you promptly if a breach occurs that may have compromised the privacy or security of your information. We reserve the right to make changes to this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. Any changes made will affect the protected health information we maintain at that time. We will provide a revised copy of the notice to parents/legal guardians upon request on or after the effective date of revision. WE WILL NOT USE OR DISCLOSE YOU/YOUR CHILD'S PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION, EXCEPT AS DESCRIBED IN THIS NOTICE. Last Revised 08/15/2023 If you have any questions regarding this Notice or wish to receive additional information about our privacy practices, please contact our office. If you believe your privacy rights have been violated, you may file a complaint at our service location either in person or by mail. CONSENT All information is private and not shared with any outside parties. Agreement of Informed Consent and the HIPAA Privacy Policy described above and the information below must be completed before any services can be provided. Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms, and that you have received the above-mentioned HIPAA notice form described above. Consent by all parents/legal guardians (those with legal custody) is required. First Name Last Name Email Electronic Caregiver Signature * Date *
