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Terms and Policy

Notice of Privacy Practices

Bevill and Associates LLC2524  Valleydale Rd

Suite 100
Birmingham, 35244
205-610-9319

Your Information. Your Rights. Our Responsibilities.


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.


Your Rights

You have the right to:

- Get a copy of your paper or electronic medical record

- Correct your paper or electronic medical record

- Request confidential communication

- Ask us to limit the information we share

- Get a list of those with whom we've shared your information

- Get a copy of this privacy notice

- Choose someone to act for you

- File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

- Tell family and friends about your condition

- Provide disaster relief

- Include you in a hospital directory

- Provide mental health care

- Market our services and sell your information

- Raise funds

Our Uses and Disclosures

 We may use and share your information as we:

- Treat you

- Run our organization

- Bill for your services

- Help with public health and safety issues

- Do research

- Comply with the law

- Respond to organ and tissue donation requests

- Work with a medical examiner or funeral director

- Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal action


Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.


Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health

   information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.


Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete.  Ask us how to do this.

- We may say "no" to your request, but we'll tell you why in writing within 60 days.


Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

- We will say "yes" to all reasonable requests.


Ask us to limit what we use or share

- You can ask us not to use or share certain health information for treatment, payment, or our operations. 

- We are not required to agree to your request, and we may say "no" if it would affect your care.

   If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.


Get a list of those with whom we've shared information

- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.

- We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.


Get a copy of this privacy notice

- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.


Choose someone to act for you

- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

- We will make sure the person has this authority and can act for you before we take any action.


File a complaint if you feel your rights are violated

- You can complain if you feel we have violated your rights by contacting us using the information on page 1.

- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.


We will not retaliate against you for filing a complaint.


Your Choice


For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.


In these cases, you have both the right and choice to tell us to:

- Share information with your family, close friends, or others involved in your care

- Share information in a disaster relief situation

- Include your information in a hospital directory


If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.


In these cases we never share your information unless you give us written permission:

- Marketing purposes

- Sale of your information

- Most sharing of psychotherapy notes


Our Uses and Disclosures


How do we typically use or share your health information?

We typically use or share your health information in the following ways.


Treat you

- We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.


Run our organization

- We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.


Bill for your services

- We can use and share your health information to bill and get payment from health plans or other entities

Example: We give information about you to your health insurance plan so it will pay for your services.


How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research.We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.


Help with public health and safety issues

- We can share health information about you for certain situations such as:

- Preventing disease

- Helping with product recalls

- Reporting adverse reactions to medications

- Reporting suspected abuse, neglect, or domestic violence

- Preventing or reducing a serious threat to anyone's health or safety

 
Do research
- We can use or share your information for health research.


Comply with the law
- We will share information about you if a state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.


Respond to organ and tissue donation requests

- We can share health information about you with organ procurement organizations.


Work with a medical examiner or funeral director

- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.


Address workers' compensation, law enforcement, and other government requests

- We can use or share health information about you:

- For workers' compensation claims

- For law enforcement purposes or with a law enforcement official

- With health oversight agencies for activities authorized by law

- For special government functions such as military, national security, and presidential protective services


Respond to lawsuits and legal actions

- We can share health information about you in response to a court or administrative order, or in response to a subpoena.



Name of Person Responsible for HIPAA Notification:

Al Bevill


Our Responsibilities

- We are required by law to maintain the privacy and security of your protected health information.

- We will let you know promptly if a breach occurs that may have compromised the privacy or security

   of your information.

- We must follow the duties and privacy practices described in this notice and give you a copy of it.

- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.


For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.


Changes To The Terms Of This Notice


We can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website www.bevillandassociates.com .


Effective - January 1, 2018



This Notice of Privacy Practices applies to the following organizations Bevill and Associates LLC, Boyle and Associates LLS and Bevill and Boyle Partnership.



Privacy officer:

Al Bevill

2524 Valleydale Road Suite 100

Birmingham, AL 35244

206-610-9319


 Acknowledgment OF RECEIPT OF NOTICE OF PRIVACY PRACTICES


This document is to be signed by a person legally responsible for the patient's medical decisions relative to the treatment situation.

I, hereby acknowledge that Bevill and Associates LLC has either offered me or provided me with a copy of the Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information.

I understand that if I have questions or complaints I may contact:


Al Bevill

2524 Valleydale Rd Suite 100

Birmingham. AL 35244

205-610-9319


I also understand that I am entitled to receive updates upon request if Bevill and Associates LLC amends or changes the Notice of Privacy Practices in a material way.



IF SIGNATURE OBTAINED FROM PERSON OTHER THAN A LEGALLY RESPONSIBLE INDIVIDUAL, ACTION TAKEN TO OBTAIN LEGAL SIGNATURE


- Given to above signee

- Sent home via U.S. Mail

- The advised person bringing in patient that policy is available on our website www.bevillandassociates.com


In either situation, the parent/legal guardian must sign and return this form either in person or by mail to:


Bevill and Associates LLC

Attn: HIPAA Contact.

2524 Valleydale Road 

Suite 100

Birmingham, AL 35244


( Type Full Name )
( Full Name )
CONSENT FOR TREATMENT

CONSENT FOR TREATMENT: I hereby consent to the treatment provided by Bevill and Associates LLC and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs.

( Type Full Name )
( Full Name )
‌AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION: I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of Bevill and Associates LLC. I authorize Bevill and Associates LLC to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that Bevill and Associates LLC may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent.

( Type Full Name )
( Full Name )
‌Confidentiality Statement for Clients, Visitors, and Guests


As a client, visitor, guest or student at Bevill and Associates LLC, I understand that confidentiality is essential for the security and comfort of those entrusting themselves to Bevill and Associates LLC's care. I commit to taking seriously the necessity not to reveal the identity of any person I may see while at Bevill and Associates LLC. I understand that any disclosure of patient information, including the person's presence in treatment, or a description of any person without specific written consent from that person may be in breach of this code. 


I agree to maintain the confidentiality of those receiving care at Bevill and Associates LLC in order to facilitate a safe and secure environment for treatment for others and me. I acknowledge that any request for information will be turned over to the director who will release such information within policy guidelines of Bevill and Associates LLC.

( Type Full Name )
( Full Name )