PRIVACY NOTICE OF DRUMGOOLE COUNSELING SERVICES, INC.
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE
PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) that prescribes legal duties
and privacy practices to protect the privacy of your individual identifiable health information;
this is, Protected Health Information (PHI), as that term is defined in the HIPAA under A
Information.
THE EFFECTIVE DATE OF THIS NOTICE IS April 1, 2014. Drumgoole Counseling Services, Inc.
is required to follow the terms of this Notice until it is replaced. Drumgoole Counseling Services, Inc. may make changes to the terms of this Notice at any
time.
Upon your request, we will provide you with a copy of the current Notice. Drumgoole Counseling
Services, Inc. reserves the right to make the changes apply to your Information
maintained in our files before and after the effective date of the new Notice. The following is a
general description of how Federal and State law permits us to use and disclose your
Information.
Purposes for which Drumgoole Counseling Services, Inc. May Use or Disclose Your Mental
Health Information with your Consent
Drumgoole Counseling Services, Inc. may request your consent for the use and/or
disclosure of your Information for treatment, payment or health care operations as described
below:
• Treatment. Drumgoole Counseling Services, Inc. with use and disclose your Information to
provide, coordinate, or manage your mental health care and any related services. Drumgoole Counseling Services, Inc. may disclose your Information to physicians, therapists, other mental
health providers, or other health care providers who are treating you or assisting in your
diagnosis, treatment, or recovery.
• Payment. Your Information will be used and disclosed, as needed, to obtain payment for your
mental health care services. This may include certain activities that your health insurance plan
undertakes before it approves or pays for the mental 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 utilization review activities. If more than
one, third party payer is responsible for payment for your health care, Drumgoole Counseling Services, Inc. may disclose your Information to more than one health plan and those
health plans may share your Information with each other. Your Information may also be used
and disclosed as needed to obtain payment for mental health care services rendered to you by
other providers.
• Mental Health Care Operations. Drumgoole Counseling Services, Inc., may use or disclose,
as needed, your Information in order to support my delivery of mental health care services.
Drumgoole Counseling Services, Inc. may call you by name in the waiting room area.
Drumgoole Counseling Services, Inc. may use or disclose your Information, as necessary, to
contact you to schedule an appointment (via phone or email) or remind you of your appointment.
• Drumgoole Counseling Services, Inc. may share your Information with third party
Business Associates who perform various administrative services. For example, those within
Drumgoole Counseling Services, Inc., or with whom Drumgoole Counseling Services, Inc. contracts, who perform billing services, transcription services, record retention, or other
professional consultants. Whenever an arrangement between a Business Associate and me
involves the use or disclosure of your Information, we will have a written contract that contains
terms that will protect the privacy of your Information.
• Health Care Services. Your Information may be used and disclosed to contact you and to give
you information about treatment alternatives or other health benefits and services that may be of
interest to you.
Uses and Disclosures With Your Verbal Consent
Your Information may be disclosed to a family member, friend, or other person designated by
you or as designated by the law, if you verbally agree.
Uses and Disclosures with Your Written Authorization
Except as provided below, your Information will not be used for any non-routine purposes unless
you give your written authorization to do so. If you give written authorization to use or disclose
your Information for a purpose that is not described in this Notice, then, with certain exception,
you may revoke it in writing at any time. Your revocation will be effective for the Information
Drumgoole Counseling Services, Inc. maintains, unless Drumgoole Counseling Services, Inc. has taken action in reliance on your authorization.
Uses and Disclosures Without Your Consent
As required by law;
• To comply with legal proceedings, such as a court or administrative order or subpoena;
• To law enforcement officials for limited law enforcement purposes;
• To a coroner, medical examiner, or funeral director about a deceased person;
• To avert a serious threat to your health or safety or the health or safety of others;
• To a governmental agency authorized to oversee the mental health care system or government
programs;
• To federal officials for lawful intelligence, counterintelligence, and other national security
purposes; and
• To public mental health authorities for public health purposes.
Your Rights
You may make a written request to me to do one or more of the following concerning your
Information:
• Put additional restrictions on use and disclosure of your Information.
• Communicate with you in confidence about your Information by a different means than
Drumgoole Counseling Services, Inc. is currently doing.
• See and get copies of your Information.
• Receive a list of disclosures of your Information that Drumgoole Counseling Services, Inc.
has made for certain purposes for six (6) years prior to your request (after April 14, 2003), with
certain exceptions permitted by law, which includes exceptions for disclosure made directly to
you or made pursuant to your authorization.
If you want to exercise any of these rights or require further information about privacy practices,
please contact me at the address below. In certain instances, Drumgoole Counseling Services, Inc. is not required to agree to your request. Drumgoole Counseling Services, Inc. will give
you the necessary information and forms for you to complete and return to request your
Information. Drumgoole Counseling Services, Inc. is permitted, by law, to charge you a fee
for copying any documents requested in accordance with your rights as listed above. (Fee $1.00
per page.)
Complaints
If you believe that Drumgoole Counseling Services, Inc. violated your privacy rights, you
have the right to complain to me or to the Secretary of the U.S. Department of Health and
Human Services (DHHS) at 200 Independence Avenue, S. W., Washington, D.C. 20201 or by calling (202) 619-025. You may file a written complaint with me at the address below. An individual must file a complaint within 180 days of when he/she knew or should have known that
the act or omission occurred, unless the time limit is waived by the Secretary of DHHS.
Drumgoole Counseling Services, Inc., will not retaliate against you if you choose to file a
complaint.
Contact Address:
Jonathan Drumgoole, NCC, LCPC
Drumgoole Counseling Services, Inc.
1212 Churchville Road, Suite 201
Bel Air, MD 21014