84 Hospital Ave , Danbury, CT 06810
81 Holly Hill Lane; 2
nd Floor Greenwich, CT 06830
Phone: 203-792-0400
Fax: 203-792-0404
HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: January 1, 2024
The confidentiality of your personal health information is very important to us. Your health information includes records
that we create and obtain when we provide you care, such as a record of your symptoms, examination and test results,
diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information
that we maintain related to your care. This Notice describes how physical & mental health information about you may be
used and disclosed, your rights regarding this information, and how you can get access to this information. Please
review it carefully. If you have any questions about this Notice, please contact: The Office Administrator, Contemporary
Care.
This Notice describes the privacy practices at Contemporary Care.
We are required by law to:
Maintain the privacy of protected health information as required by law
Give you this notice of our legal duties and privacy practices regarding your health information
Follow the terms of the Notice currently in effect.
How we may use and disclose your health information:
Described as follows are the ways we may use and disclose your health information. Except for the following
purposes we will use and disclose your health information only with your written permission. You may revoke such
permission at any time by writing to the TMS Coordinator.
Treatment. We may use and disclose your physical & mental health information for your treatment and to provide you
with treatment-related health care services. For example, we may disclose your physical & mental health information to
doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical
care and need the information to provide you with medical care. We may also share physical & mental health arid
substance abuse information about you with other healthcare providers, agencies or facilities who are treating you for a
medical or psychological condition, in order to provide or coordinate the different things you need, such as prescriptions
or types of therapy. We also may disclose mental health information about you to people who may be involved in your
continuing mental health or medical care after you leave our practice, such as other health care providers, transport
companies, community agencies and family members.
Payment. We may use and disclose your physical & mental health information so that others or we may bill and receive
payment from you, an insurance company, or a third party for the treatment and services you received. For example, we
may give information to your health plan so that they will pay for your treatment
Health Care Operations. We may use and disclose your physical & mental health information to evaluate and improve
our medical care and to operate and manage our office. For example, we may use and disclose information to a peer
review organization or a health plan that is evaluating our care. We may also share information with others that have a
relationship with you for their health care operation activities.
Appointment Reminders. Treatment Alternatives. and Health-Related Benefits and Services. We may use and disclose
your physical & mental health information to contact you and remind you of your appointment, to tell you about treatment
alternatives or health-related benefits and services you could use.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share your physical & mental
health information with a person involved in, or paying for, your care (such as your family or a close friend). We may
notify your family about your location or condition. Any such disclosure will be limited to information directly related to
the person’s involvement in your care. If you are available, we will provide you an opportunity to object before
disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some
other emergency circumstance, we will use our professional judgment to determine what is in your best interest
regarding any such disclosure.
Disaster Relief. We may disclose physical & mental health information about you to government entities or private
organizations (such as the Red Cross) to assist in disaster relief efforts. If you are available, we will provide you an
opportunity to object before disclosing any such Information. If you are unavailable because, for example, you are
incapacitated, we will use our professional judgment to determine what is in your best interest and whether a
disclosure may be necessary to ensure an adequate response to the emergency circumstances.
Research. We may use and disclose your physical & mental health information for research. For example, a research
project may involve comparing the health of patients who received one treatment to those who received another for the
same condition. Before we do so, the project needs to go through a special approval process. Even without special
approval, we may permit researchers to look at records to help identify patients who may be included in their research, as
long as they do not remove or copy any of your physical & mental health information.
As Required by Law. Wewill disclose your physical & mental health information 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 your physical & mental health information when
necessary to prevent a serious threat to the health and safety of you, another person, or the public. Disclosures will be
made only to someone who can help prevent or reduce the threat.
Business Associates. We may disclose your health information to our business associates that perform functions on our
behalf or provide us with seMces if necessary. For example, we may use another company to perform billing services
on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed
to use or disclose the information for any other purpose than appears in their contract with us.
Organ and Tissue Donation. If you are an organ donor, we may release mental health information to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to
facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release your physical & mental health
information as required by military command authorities. If you are a member of a foreign military we may release
your physical & mental health information to the foreign military command authority.
Workers Compensation. We may release your physical & mental health and substance abuse information for workers
compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health Disclosures We may disclose physical & mental health information about you for public health purposes.
These purposes generally include the following: (1) preventing or controlling disease (such as cancer and tuberculosis),
injury or disability; (2) reporting vital events such as births and deaths; (3) reporting child abuse or neglect; (4) reporting
adverse events or surveillance related to food, medications or defects or (5) reporting problems with products; (6)
notifying persons of recalls, repairs or replacements of products they may be using; (6) notifying a person who may
have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; (7) notifying the
appropriate government authority if we believe a patient has been the victim of abuse or neglect and make this
disclosure as authorized or required by law; (8) notifying the coroner of a patient’s death; (9) notifying emergency
response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal
law; (10) notifying multidisciplinary personnel teams relevant to the prevention, identification, management, or treatment
of an abused child and the child’s parents or an abused elder or dependent adult.
Health Oversight Activities. We may disclose your physical & mental health information to a health oversight agency
tor activities authorized by law. These may include audits, investigations, inspections, and licensure. These activities
are necessary for the government to monitor the health care system, government programs, and compliance with
civil nghts laws.
Coroners. Medical Examiners. and Funeral Directors. We may release your physical & mental health information to a
C0roner, medical examiner, or funeral director to identify a deceased person or cause of death, or other similar
circumstance.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your physical & mental health
information in response to a court or administrative order. We may disclose your physical & mental health information in
response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if
efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release as appropriate your physical or mental health information to law enforcement: (1)
pursuant to a subpoena by law enforcement; (2) as needed for the protection of others; or (3) if there is a court order,
subpoena, or other le9al process for release of lhe
information. Information may also be released to (1) law enforcement without their request in order to protect others whom
you threaten to injure and to
(2) persons who are in danger from a threat you have made.
Department of Justice. We may disclose limited information to the California Department of Justice for movement
an 1dent1ficabon purposes about certain criminal patients, or regarding persons who may not purchase, possess or
control a firearm or deadly weapon.
Protection of Elective Constitutional Officers. We may disclose mental health information about you to government law
enforcement agencies as needed for the protection of federal and state elective constitutional officers and their families.
National Security and Intelligence Activities. We may disclose your physical & mental health information to authorized
federal officials for intelligence and other national security activities authorized by law.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or in custody we may disclose your
information 1) for the institution to provide you with health care, 2} to protect your health and safety or that of others, and
3} for the safety and security of the institution.
YOUR RIGHTS REGARDING YOUR PHYSICAL & MENTAL HEAL TH INFORMATION
Right to Inspect and Copy. You have the right to inspect and or receive a copy of your physical & mental health
information and billing records. In order to do so, you need to send a written request to the Management. If you
request a copy of the information, there is a fee for these services. We may deny your request to inspect and/or to
receive a copy in certain very limited circumstances.
Right to Amend. You have the right to request an amendment to your records by written request to the Management.
Right to an Accounting of Disclosures. You have a right to an accounting of certain disclosures by written request to the
TMS Coordinator.
Right to Request Restrictions. You have the right to request restriction or limitation on your physical & mental health
information used for treatment, payment or health care operations. You may request us to limit disclosure to
someone involved in your care or in payment for your care (such as a spouse) by written request to THE OFFICE
MANAGER. We are not required to agree with your request, but we will try to comply.
Right to Request Confidential Communication. You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. You can ask, for example, that we contact you only by mail or at
work. Your written request must specify how or where you wish to be contacted and be addressed to THE OFFICE
MANAGER. We will accommodate reasonable requests.
QUESTIONS OR COMPLAINTS. If you have any questions about this Notice1 please contact the TMS Coordinator. If
you believe Your Privacy Rights have been violated, you may file a complaint with the Office Manager. To file a
complaint with the Secretary of the Department of Health and Human Services contact the Department of Health and
Human Services, Office of Civil Rights, J.F. Kennedy Federal Building, Room 1875, Boston, MA 02203 (PHONE)
(800) 368-1019, (FAX) (617) 565-3809, (TDD) {800) 537-7697. You will not be penalized for filing a complaint.
OTHER USES OF YOUR HEAL TH INFORMATION. Other uses and disclosures of physical & mental health information
not covered by this Notice will be made only with your written permission. If you provide us permission to disclose such
information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no
longer disclose such information about you for the reasons covered by your written permission. You understand that we
are unable to take back any disclosures we have already made with your permission, and that we will retain our records
of the care provided to you as required by law.
CHANGES TO THIS NOTICE
We may change this notice and make it effective for medical information we already have about you as well as new
Information. The current notice will be posted and available at all times. You have a right to request a paper copy of the
current notice at any visit or by written request to the Office Manager.
Patient Acknowledgement of Receipt
of Hf PAA Notice of Privacy Practices:
Patient Name: _______________ Birthdate: ____ _
(please print)
Maiden/other name used(ifapplicable): __________ _
I acknowledge that I have received a copy of the privacy practice of Contemporary Care. LLC.
A photocopy or facsimile of this signature is as valid as the original.
Patient Signature: ______________ Date_______ _