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THIS NOTICE DESCRIBES HOW MEDICAL, INCLUDING MENT AL HEALTH, INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. During the process of providing services to you, Mark Rush will obtain, record, and use mental health and medical inf;rmation about you that is Protected Health Information. Ordinarily that information is confidential and will not be used or disclosed, except as described below. 
A. General Uses and Disclosures Not Requiring the Individual's Consent. 
Practitioner will use and disclose Protected Health Information in following ways. 
1. Treatment. Treatment refers to the provision, coordination, or management of health care, including mental health care, and related services by one or more health care providers. For example, Practitioner will use your information to plan your course of treatment. As to other examples, Practitioner may consult with professional colleagues or ask professional colleagues to cover calls or the practice for Practitioner and will provide the information necessary to complete those tasks. 
2. Payment. Payment refers to the activities undertaken by Practitioner to obtain or provide reimbursement for the provision of health care. Practitioner will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company or other third-party payer for services provided. The information provided to insurers and other third-party payers may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name/identifier, and other information about your condition and treatment. If you are covered by Medicaid, information will be provided to the State of Colorado's Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received. 
3. Health Care Operations. Health Care Operations refers to activities undertaken by Practitioner that are regular functions of management and administrative activities of the practice. For example, Practitioner may use or disclose your health information in the monitoring of service quality, staff evaluation, and obtaining legal services. 
4. Contacting the Individual. Practitioner may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you. 
5. Required by Law. Practitioner will disclose Protected Health Information when required by law or necessary for health care oversight. This includes, but is not limited to when (a) reporting child abuse or neglect; (b) a court-ordered release of information; (c) there is a legal duty to warn or take action regarding imminent danger to others; (d) the Individual is a danger to self others or gravely disabled (e) a coroner is investigating the Individual's death; or (f) to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, or regulatory compliance. 
6. Crimes on the Premises or Observed by the Provider. Crimes that are observed by Practitioner or Practitioner's staff, crimes that are directed toward Practitioner or Practitioner's staff, or crimes that occur on the premises will be reported to law enforcement. 
7. Business Associates. Some' of the functions of Practitioner may be provided by contracts with Business Associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, Protected Health Information will be provided to those contractors as is needed to perform their contracted tasks. Business Associates are required to enter into an agreement maintaining the Protected Health Information privacy of the Protected Health Information released to them. 
8. Research. Practitioner may use or disclose Protected Health Information for research purposes if the relevant limitations of the Federal HIPAA Privacy Rule are followed. 45 C.F.R. § 164.512(i). 
9. Involuntary Treatment. Information regarding Individuals who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third-party payers and others, as necessary to provide the care and management coordination needed. 
10. Family Members. Except for certain minors, incompetent Individuals, or involuntarily treated Individuals, Protected Health Information cannot be provided to family members without the Individual's consent. In situations where family members are present during a discussion with the Individual, and it can be reasonably inferred from the circumstances that the Individual does not object, information may be disclosed in the course of that discussion. However, if the Individual objects, Protected Health Information will not be disclosed. 
11. Emergencies. In life threatening emergencies, Practitioner will disclose information necessary to avoid serious harm or death. 
B. Statements That Certain Uses and Disclosures Require Authorization. Practitioner must obtain your Authorization in order to use or disclose your Protected Health Information as follows: (1) for marketing purpose (2) to sell your Protected Health Information to a third party; and (3) most uses and disclosures of your psychotherapy notes. 
C. Individual Authorization or Release of Information. Practitioner may not use or disclose Protected Health Information in any other way than set forth in this Notice without a signed Authorization. When you sign an Authorization, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent Practitioner has already taken action in reliance thereon. 
A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the Protected Health Information the provider has regarding you, in the designated record set. If records are used or maintained as 'electronic health record, you have a right to receive a copy of the PHI maintained in the electronic health record in an electronic format. However, you do not have the right to inspect or obtain a copy of psychotherapy notes. There are other limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask Practitioner. 
B. Amendment of Your Record. You have the right to request that Practitioner amend your Protected Health Information. Practitioner is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. To make a request, ask Practitioner. 
C. Accounting of Disclosures. You have the right to receive an Accounting of certain disclosures Practitioner has made regarding your Protected Health Information. However, that Accounting does not include disclosures that were made for the purpose of Treatment, Payment, or Health Care Operations. In addition, the Accounting does not include disclosures made to you, disclosures made pursuant to a signed Authorization, or disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an Accounting. To make a request, ask Practitioner. 
D. Additional Restrictions. You have the right to request additional restrictions on the use or disclosure of your health information. Unless you pay for your services out of pocket, Practitioner does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. If you pay for a service out of pocket, you are permitted to demand that information regarding the service not be disclosed to your health plan or insurance. To make a request, ask Practitioner. 
E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of Protected Health Information from Practitioner by alternative means or at alternative locations. For example, if you do not want Practitioner to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask Practitioner.
F. Breach Notification. In the event of any breach of your unsecured PHI, 
Practitioner will notify you of such breach within sixty (60) days of the date Practitioner learns 
of the breach G. Copy of this Notice: You have a right to obtain another copy of this Notice upon 
A. Privacy Laws. Practitioner is required by State and Federal law to maintain the privacy of Protected Health Information. In addition, Practitioner is required by law to provide Individuals with notice of Practitioner's legal duties and privacy practices with respect to Protected Health Information. That is the purpose of this Notice. 
B. Terms of the Notice and Changes to the Notice. Practitioner is required to abide by the terms of this Notice, or any amended Notice that may follow. Practitioner reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all Protected Health Information that it maintains. When the Notice is revised, the revised Notice will be posted at Practitioner's service delivery sites and will be available upon request. 
C. Complaints Regarding Privacy Rights. If you believe the provider has violated your privacy rights, you have the right to complain to Practitioner. You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to 
Regional Manager, Office for Civil Rights 
U.S. Department of Health & Human Services 
999 18th Street, Suite 417 
Denver, Colorado 80294 
Phone: (800) 368-1019 
TDD: (800) 537-7697 
Fax: (303) 844-2025 
It is the policy of Practitioner that there will be no retaliation for your filing of such complaints. 
D. CONTACT INFORMATION. If you have questions about this Notice or desire additional information about your privacy rights, please contact our Privacy Officer:
Mark Rush, Ph.D.
4770 E. Iliff Ave. Suite # 108
Denver, CO 80222
E. EFFECTIVE DATE: 11/17/2013