HIPAA Information/Privacy Notice

 

 

PRIVACY NOTICE

 

Allegheny Behavior Analysis Services is required by law to keep your health information safe.  This information may include, but is not limited to:

  • Information received from doctors, educators, or other service providers

  • Medical history information

  • Assessment results

  • Treatment data and notes

  • Insurance information

  • Progress and other written reports

We are required by law to provide you with a copy of our privacy notice.  This notice informs you how you or your child’s health information may be used or shared.  

By signing this page, you acknowledge that you have been given a copy of our privacy notice.

Client Name: ________________________________________

Client D.O.B.: ________________________________________

Parent Name: ________________________________________

Parent Signature: _____________________________________

Date: ______________________________________________

 

 

 

 

 

 

HEALTH INSURANCE PORTABILITY

AND ACCOUNTABILITY ACT

YOUR PRIVACY RIGHTS

 

This notice describes how medical information about you may or your child may be used and disclosed, as well as how you can obtain access to this information.  Please review it carefully, and ask any questions you may have prior to signing that you have received it.

Allegheny Behavior Analysis Services is required by the Health Insurance Portability and Accountability Act (HIPAA) to keep your Personal Health Information (PHI) safe, and to provide you with a copy of this notice.  This information may include, but is not limited to the following:

  • Information received from doctors, educators, or other service providers

  • Medical history information

  • Assessment results

  • Treatment data and notes

  • Insurance information

  • Progress and other written reports

We may use your child’s health information without your permission for the following reasons:

Treatment: we may share your information with doctors and other health care providers who care for your child.  For example, if your developmental pediatrician orders ABA therapy, we will share the results of our treatment with that doctor.

Payment: we may use and share information about the treatment your child receives with your health insurance company or other payer to receive payment for the services.  This may include sharing important medical information.  We may share information to obtain permission to begin treatment, obtain permission to continue treatment, or to receive payment for treatment received.

Health Care Operations: we may use and share your child’s health information for staff training and quality assurance purposes.  For example, we may use your child’s health information to: evaluate treatment effectiveness, evaluate staff performance, and improve the quality of our services.  

Abuse and Neglect: we may share your child’s health information with government agencies when there is evidence of abuse, neglect, or domestic violence.

As Required by Law: we will share your child’s health information when we are required to by federal, state, or local law enforcement or judicial agencies.  

Public Health Risks: we may report information to public health agencies as required by law.  This may be done to help prevent disease, injury, or disability.  

Regulatory Oversight: we may use or share your child’s information to report to agencies overseeing healthcare.  This may include sharing information for audits, licensure, and inspections.

Threats to Health and Safety: your child’s health information may be shared if it is believed that it will present a threat to your child’s health and safety or the health and safety of others.

When your permission is needed to use or share your health information:

You must give us your permission to use or share your child’s health information for any situation that is not listed on this notice.  You will be asked to sign a form, called an authorization, to allow us to share your child’s information.  You are allowed to withdraw or revoke this authorization at any time.  However, we will not be able to get information back that has already been shared with your permission.

You have the right to:

Ask us not to share your child’s information: you can ask us not to share your child’s information for treatment, payment, or healthcare operations.  You can also ask us not to share information with people involved in your child’s care, such as family members or friends.  You must ask for limits in writing.  However, there may be times that we must share information as required by law, and under such circumstances, we do not have to grant your request.  

View and Copy Your Child’s Health Information: you have the right to see and obtain copies of your child’s health information.  You have the right to view and obtain copies of treatment, medical, and billing information.  You may not be able to view or copy information gathered for a court case and or copyrighted materials, such as test protocols.

Request Changes to Your Child’s Health Information: you can ask us to change information that you think is wrong.  You can also ask that we add information that is missing.  You must provide a written request, and we do not have to make the change.

Request a report of how and when your child’s information was used or shared: you can request in writing for information regarding when your child’s information was shared and who we shared it with.  

Request a copy of this notice at any time.

File complaints: you can file complaints with us or with the government if you think that your child’s information was used or shared in a way that is not permitted, you were not allowed to view or copy your child’s information, or any of your rights were denied.  Additional information on filing complaints can be found at www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.

Changes to the Information in this Notice: we may change this notice at any time.  Changes may apply to information we already have in your file and any new information.  You will be provided with a copy of the revised notice.  

Allegheny Behavior Analysis Services, LLC

3000 Mcknight East Dr Suite 102, Pittsburgh, PA 15237

Main:  (412)230-8615

Make a secure credit/debit card

payment using the "Buy Now" link