FLYING SOLO COUNSELING LLC

Cheryl Klein, M. Div., Licensed Pastoral Counselor

Notice of Privacy Practices (NPP)

This notice describes how medical information may be used and disclosed and how you can get access to this information.

COMMITMENT TO YOUR PRIVACY

This practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am required by law to keep your information private. These laws are complicated but I must provide you this important information. This is a shorter version of the full, legally required NPP and you are entitled to receive a copy of this to read  and refer to it for more information. However, I am unable to cover all possible situations and suggest that you contact me directly, as the Privacy Officer of this practice (see below) about any questions or problems.

The information about your health which I get from you or others will be used mainly to provide you with treatment, to arrange payment for my services, and for some other business activities which are called, in the law, health care operations. After you have read this NPP, you will be asked to sign a consent form to allow use and sharing of your information. If you do not sign the consent form, I cannot treat you.

If I or you want o use of disclose (send, share, release) your information for any other purposes, this must be discussed with you and you will be asked to sign an Authorization Form to allow this. Of course, I will keep your health information private but there are some times when the laws require use or sharing of it. For example:

• When there is a serious threat to your health or safety or the health and safety of another individual of the public; information will only be share with a person or organization who is able to help prevent or reduce the threat.
• Some lawsuits and legal or court proceedings.
• If a law enforcement official requires me to do so.
• For Worker's Compensation and similar benefit programs.

There are some other situations like these but which don't happen very often. They are described in the longer version of the NPP.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask that you be called at home and not at work to schedule or cancel an appointment. I will do my best to do as you ask.

2. You have the right to ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at the health information I have about you such as your medical and billing records. You can get a copy of these records for a fee of $15. Please contact me as the Privacy Officer for this office to arrange how to see your records. However, under these privacy rules, there is no access to any psychotherapy notes which I may keep.

4. If you believe the information in your records is incorrect or missing important information, you may ask me to make some kinds of changes (called "amending") to your health information. This request must be made in writing and sent to me as the Privacy Officer, and you must state the reasons you want to make the changes.

5. You have the right to a copy of this notice. IF this NPP is changed, the new version will be posted in the office waiting room and you may always get a copy of the NPP from the Privacy Officer.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me as the Privacy Officer or with the Secretary of the Department of Health and Human Services. All complaints must be in writing, Filing a complaint will not change the health care provided to you in any way.

If you have any questions regarding this notice or the health information policies in this office, please contact the Privacy Officer, who is Cheryl Klein, and can be reached by phone at (207) 892-7656 or by email to WeFlySolo@hotmail.com The effective date of this notice is April 14, 2003.

Also, you may have other rights which are granted to you by the laws of our state and these may be the same or different from the rights described above. I will be happy to discuss these situations with you at this time or as they arise.

(Copy to be signed and completed by client at first office visit).