Open Book Therapy

Office Policies

Here at Open Book Therapy believe in honesty and transparency. That is why we think it is important to make our office policies easily accessible. On this page you'll find explanations of our COVID-19 Office Policies, Billing Policies, Attendance Policies and anything else you may have questions about. 

COVID-19: Returning to Office / In Person Session Policies

Below you will find the policy and procedure for individuals wanting to return to in person services at Open Book Therapy's Lincoln Square Location Policy and Procedure & Consent: Returning to In-Office/In-Person Psychotherapy Services Client Version This Consent for Returning to In-Person Psychological Services is a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Please read this document carefully and let me know if you have any questions. Assumed Risk Acknowledgement The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with in person sessions. The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other patients, the characteristics of the virus, and the characteristics of in person sessions, there is an elevated risk of you contracting the virus simply by being in our office. Moreover, to get to this office, you may have to come into contact with the general public. Traveling in public, utilizing public transportation, using public restrooms and being in confined spaces with others (elevators, my office, etc.) leaves you vulnerable to COVID-19. Open Book Therapy’s Response to COVID: The threat of COVID-19 is ongoing throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, teletherapy services may not be adequate, and in-person services may be more appropriate.

Below you will find the policy and procedure for individuals wanting to return to in person services at Open Book Therapy's Lincoln Square Location Policy and Procedure & Consent: Returning to In-Office/In-Person Psychotherapy Services Client Version This Consent for Returning to In-Person Psychological Services is a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Please read this document carefully and let me know if you have any questions. Assumed Risk Acknowledgement The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with in person sessions. The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other patients, the characteristics of the virus, and the characteristics of in person sessions, there is an elevated risk of you contracting the virus simply by being in our office. Moreover, to get to this office, you may have to come into contact with the general public. Traveling in public, utilizing public transportation, using public restrooms and being in confined spaces with others (elevators, my office, etc.) leaves you vulnerable to COVID-19. Open Book Therapy’s Response to COVID: The threat of COVID-19 is ongoing throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, teletherapy services may not be adequate, and in-person services may be more appropriate.

Attedence, Late Cancellation and No Show Policies

Below you will find the attedence, late cancellation and no show policies for Open Book Therapy current client's Open Book Therapy Attedence, Late Cancellations and No Call/No Show Policies: • Sessions are 45-60 minutes, depending on your needs and insurance carrier. • Open Book Therapy observes the right to cancel reoccuring appointments if individuals cancel or miss their scheduled appointment times three times in a row. • Cancellations without notice/no notice or missed appointments (no call no show) will be subject to full fee charge no less than $175.00. (Initial intakes - $175.00 / Follow-Up Appointments - $150.00). You will be charged the full fee of your session (NOT your co-pay or co-insurance amount), which is dependent on your provider and the type of appointment. If you are unclear about this rate, please talk with your individual provider. • Cancellations with less than 12-24 hours notice will be subject to a $75.00 late cancelation fee. Example: if your appointment is Thursday at 7PM and you cancel at Thursday at 9AM, that will be considered a late cancelation. If you are unclear about this rate, please talk with your individual provider. • If fees for services are not paid in a reasonable amount of time, and attempts have been made to resolve the financial matter to no avail, a client account may be sent to a collection service. • If fees for services are not paid in a reasonable amount of time, and attempts have been made to resolve the financial matter to no avail, a client account may be sent to a collection service. INCLEMENT WEATHER POLICY: • If there are extreme weather conditions that make it dangerous for you to travel to the office for your session, please let your individual clinician know as soon as possible OR no later than 7:00AM the morning of your appointment and you will not be charged. If your appointment is at 7:00AM, you need to notify us at least 2 hours prior to your appointment to avoid the cancellation fee. If you wait to cancel your appointment until AFTER 7:00AM, we will need to charge as if appointment is a late cancellation.

Insurance and Billing Policies

Below you will find the insurance and billing policies for Open Book Therapy current client's Open Book Therapy Insurance and Billing Policies: INSURANCE: • Therapy is a commitment of time, energy and financial resources. If you have health insurance, it is important for you to verify your mental health benefits so you understand your coverage prior to your appointment. Some insurance companies require a pre-certification before the first appointment or they will not cover the cost of services. If you are confused about how to check your insurance benefits, please refer to the document that you received in your New Client Email. • YOU, not your insurance company, are ultimately responsible for the payment of your services. This is regardless of what we or your insurance company quotes your benefits as. Acceptable forms of payment include cash, check and major credit cards. • Most insurance agreements require you to authorize us to provide a clinical diagnosis and sometimes additional clinical information. If you request it, we will provide you with any information we or the billing company we employ sends to your insurance company. This information will become part of the insurance company’s files. Insurance companies claim to keep information confidential, but you should check with your insurance company directly if you have questions about their confidentiality practices. • If you DO NOT want a mental health diagnosis being a part of your medical record, you MUST SELF-PAY. • If you are an out-of-network client, you will be responsible for paying the full fee of the service on the same day as your appointment. The full fee is dependent on which Clinician you see and what their particular rate is. If you don’t know the rate you are responsible for paying, please talk to your Clinician. • Should you need special accommodations like a sliding scale fee due to lack of insurance coverage or financial hardship, please discuss this with you individual provider. BILLING: • Insurance requires that we do not bill you until your insurance processes. This may mean that you may accrue a balance while we wait for your insurance to process. If you are concerned about this, please discuss this with your individual provider. • If you use insurance and your insurance has processed your claims, you will be charged 1-3 weeks after your session. • If you self-pay and DO NOT use insurance, you will be charged on the day of your session and payment is expected in full. • If you have accrued a balance, you must pay 25% of your balance plus the cost of the session (co-pay, co-insurance, deductible, etc.) in order to continue services. • An account that has not been paid for more than 60 days without payment arrangements being made will be eligible for collection proceedings. This may involve legal action, hiring a collection agency or going through small claims court. If legal action or collection assistance is necessary, its costs will be included in the claim. In most collection situations, the only information we release regarding a client's treatment is his or her name, the nature of services provided and the amount due. RATES: • For individual therapy sessions, rates will depend on the therapist you are seeing and whether you are using insurance or are a self-pay client. If you are using insurance, costs will depend on your plan’s copay, your deductible, and out-of- pocket max. Insurance rates are NOT the same as self-pay rates • In addition to you regular appointments, your care may require additional professional services. The same hourly rate will apply to these services, although we will break down the hourly cost if we work for periods of less than one hour. These other services may include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries and the time spent performing any other services you may request of your therapist. LEGAL AND COURT-RELATED SERVICES: • We DO NOT provide or perform evaluations for custody, visitation, or other forensic matters. Therefore, it is understood and agreed that your therapist cannot and will not provide any testimony or reports regarding issues of custody, visitation or fitness of a parent in any legal or administrative proceedings. • If your therapist is contacted by an attorney regarding your treatment or treatment of your child (either at your behest or related to a legal matter you are involved in), please note the following: • We charge $400 per hour to prepare for and/or attend any legal proceeding and for all court related services including travel time to and from the location of the proceeding. Fees for legal and court related services must be paid prior to the scheduled court hearing or deposition. Charges for court related services are not covered by insurance. • Court related services include: talking with attorneys, preparing and reviewing documents, traveling to court or deposition venue, attending depositions and court hearings/trials. • If our fee is not paid by the court or attorneys, you will be charged for the time we spend responding to legal matters. All fees for legal matters must be paid in advance of the legal proceeding in question. • You will be charged for any costs we incur responding to attorneys in your case, including but not limited to fees we are charged for legal consultation and representation by our attorneys.

Informed Consent for Telehealth and Electronic Communications

Below you will find Open Book Therapy's policy regarding telehealth and electronic communication Informed Consent to Tele-Psychotherapy and Tele-Health Communications Open Book Therapy Informed Consent for Tele-Psychotherapy and Tele-Health Communications. This Informed Consent for Tele-Psychotherapy and Tele-Health Communications contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let us know if you have any questions. When you sign this document, it will represent an agreement between your self and the Open Book Therapy organization. ABOUT THIS NOTICE: Benefits and Risks of Tele-Psychotherapy and Tele-Health Communications • DEFINING TELE-PSYCHOTHERAPY AND TELE-HEALTH COMMUNICATIONS: • Tele-Psychotherapyand Tele-Health Communications refers to providing psychotherapyservices remotelyusing telecommunications technologies, such as video conferencing or telephone. One of the benefits of Tele-Psychotherapy and Tele-Health Communications is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Tele-Psychotherapy and Tele-Health Communications, however, requires technical competence on both our parts to be helpful. Although there are benefits of Tele-Psychotherapy and Tele-Health Communications, there are some differences between in-person psychotherapy and Tele-Psychotherapy and Tele-Health Communications, as well as some risks. For example: ISSUES RELATING TO TELE-PSYCHOTHERAPY AND TELE-HEALTH COMMUNICATIONS: • There are many ways that technology issues might impact Tele-Psychotherapy and Tele-Health Communications. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. • Crisis management and intervention. Usually, I will not engage in Tele-Psychotherapy and Tele-Health Communication with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in Tele- Psychotherapy and Tele-Health Communication, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our Tele-Psychotherapy and Tele-Health Communication work. • Efficacy. Most research shows that Tele-Psychotherapy and Tele-Health Communication is about as effective as in- person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely. ELECTRONIC COMMUNICATIONS: • We will decide together which kind of Tele-Psychotherapy and Tele-Health Communication service to use. You may have to have certain computer or cell phone systems to use Tele-Psychotherapy and Tele-Health Communication services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in Tele-Psychotherapyand Tele-Health Communication. • For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check my email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency. • Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. We will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach our office and feel that you cannot wait for our office to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If we will be unavailable for an extended time, our office will provide you with the name of a colleague to contact in our absence if necessary. CONFIDENTIALITY: • We have a legal and ethical responsibility to make our best efforts to protect all communications that are a part of our Tele-Psychotherapy and Tele-Health Communication. However, the nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, onlyusing secure networks for Tele-Psychotherapyand Tele-Health Communication sessions and having passwords to protect the device you use for Tele-Psychotherapy and Tele-Health Communication). • The extent of confidentiality and the exceptions to confidentiality that we outlined in my Informed Consent for Psychotherapy Services still apply in Tele-Psychotherapy and Tele-Health Communication. Please let our organization know if you have any questions about exceptions to confidentiality. APPROPRIATENESS OF TELE-PSYCHOTHERAPY AND TELE-HEALTH COMMUNICATIONS: • From time to time, we may schedule in-person sessions to “check-in” with one another. We will let you know if we decide that Tele-Psychotherapy and Tele-Health Communication is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. EMERGENCIES AND TECHNOLOGY: • Assessing and evaluating threats and other emergencies can be more difficult when conducting Tele-Psychotherapyand Tele-Health Communication than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in Tele-Psychotherapy and Tele-Health Communication services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. Our organization will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. • If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back; instead, call 911, or go to your nearest emergency room. Call us/your provider back after you have called or obtained emergency services. • If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the Tele-Psychotherapy and Tele-Health Communication platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call us on the phone number we provided you (872) - 216 - 6131. • If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. FEES: • The same fee rates will apply forTele-Psychotherapy and Tele-Health Communication as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session unless this has been EXPRESSLY DISCUSSED AND AGREED UPON WITH CLINICIAN. Please contact your insurance company prior to our engaging in Tele- Psychotherapy and Tele-Health Communication sessions in order to determine whether these sessions will be covered. RECORDS: • The Tele-Psychotherapy and Tele-Health Communication sessions shall not be recorded in any way unless agreed to in writing by mutual consent. We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with mypolicies. • This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions. This certifies and acknowledges that I read and/or received a copy of the Open Book Therapy's Informed Consent for Tele-Psychotherapyand Tele-Health Communication.

HIPAA: Notice of Privacy Practices

Below you will find Open Book Therapy's HIPAA Policy Regarding privacy practices Open Book Therapy - HIPAA Notice of Privacy Practices Open Book Therapy HIPAA Notice of Privacy Practice Statement HIPAA Notice of Privacy Practice Statement Patient Notice of Privacy Practices As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH Act), and associated regulations and amendments. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. ABOUT THIS NOTICE: We understand that health information about you is personal and we are committed to protecting your information. We create a record of the care and services you receive at Open Book Therapy. We need this record to provide care (treatment), for payment of care provided, for health care operations, and to comply with certain legal requirements. This Notice will tell you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to follow the terms of this Notice that is currently in effect. WHAT IS PROTECTED HEALTH INFORMATION (“PHI”)? PHI is information that individually identifies you. We create a record or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse that relates to: • Your past, present, or future physical or mental health or conditions. • The provision of health care to you. • The past, present, or future payment for your health care. HOW WE MAY USE AND DISCLOSE YOUR PHI: We mayuse and disclose your PHI in the following circumstances: • TREATMENT: We may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, your PHI may be provided to a physician or other health care provider (e.g., a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you or provide you with a service. • PAYMENT: We may use and disclose your PHI so that we can bill for the treatment and services you receive from us and can collect payment from you, a health plan, or a third party. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment. • HEALTH CARE OPERATIONS: We may use and disclose PHI for our health care operations. For example, we may use your PHI to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose information to other authorized personnel for educational and learning purposes. • APPOINTMENT REMINDERS/TREATMENT ALTERNATIVES/HEALTH-RELATED BENEFITS AND SERVICES: We mayuse and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you. • MINORS: We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. • As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law. • To AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat. • BUSINESS ASSOCIATES: We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your PHI. • MILITARY AND VETERANS POPULATIONS: If you are a member of the armed forces, we may disclose PHI as required by military command authorities. We also may disclose PHI to the appropriate foreign military authority if you are a member of a foreign military. • WORKER'S COMPENSATION: We may use or disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illness. • PUBLIC HEALTH RISKS: We may disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. • ABUSE, NEGLECT, AND DOMESTIC VIOLENCE: We may disclose PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure. • HEALTH OVERSIGHT ACTIVITIES: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. • DATA BREACH NOTIFICATION PURPOSES: We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information. • LAWSUITS AND DISPUTES: If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit. • LAW ENFORCEMENT: We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. • MILITARY ACTIVITY AND NATIONAL SECURITY: If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your PHI to authorized officials so they may carry out their legal duties under the law. • CORNERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS: We may disclose PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties. • INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the correctional institution or law enforcement official if the disclosure is necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and securityofthe correctionalinstitution. • INDIVIDUALS INVOLVED IN YOUR CARE: Unless you object in writing, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. • PAYMENT FROM YOUR CARE: Unless you object in writing, you can exercise your rights under HIPAA that your healthcare provider not disclose information about services received when you pay in full out of pocket for the service and refuse to file a claim with your health plan. DISASTER RELIEF: We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so. • FUNDRAISING ACTIVITIES: We may use or disclose your PHI, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications. Your Written Authorization if Required for Other Uses and Disclosures The folowing uses and disclosures of your PHI wil be made only with your written authorization: • Most uses and disclosures of psychotherapy notes; • Uses and disclosures of PHI for marketing purposes; and • Disclosures that constitute a sale of your PHI. • Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation Your Rights Regarding Your PHI You have the folowing rights, subject to certain limitations, regarding your PHI: • INSPECT AND COPY: You have the right to inspect, receive, and copy PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. You can only direct us in writing to submit your PHI to a third party not covered in this notice. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. • SUMMARY AND EXPLANATION. We can also provide you with a summary of your PHI, rather than the entire record, or we can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees. • ELECTRIC COPY OF ELECTRONIC MEDICAL RECORDS: If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. If the PHI is not readily producible in the form or format you request your record will be provided in a readable hard copy form. • RECEIVE NOTICE OF BREACH: You have the right to be notified upon a breach of any of your unsecured PHI. • REQUEST AMENDMENTS: If you feel that the PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the beginning of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. • ACCOUNTING DISCLOSURES: You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. The first accounting of disclosures you request within any 12- month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the list. We will tell you what the costs are, and you may choose to withdraw or modify your request before the costs are incurred. • REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or health care operations. We are not required by federal regulation to agree to your request. If we do agree with your request, we will comply unless the information is needed to provide emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer. Your request must state the specific restriction requested, whether you want to limit our use and/or disclosure; and to whom you want the restriction to apply. • REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. • REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. • PAPER COPY OF THIS NOTICE: You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may obtain a copy of this Notice by asking your therapist or contacting Kyla Dannelke, MA, LCPC - kyla@openbooktherapychi.com or 872-216-6131. • CHANGES TO THIS NOTICE: We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. • COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with Open Book Therapy at the address listed at the beginning of this Notice or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Humans Services, 200 Independence Ave., S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775 or go to the website of the Officer for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. You will not be penalized for filing a complaint.