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Privacy Policy

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Birch Grove Mental Health (the “Practice”) is committed to protecting your privacy. We are required by federal law to maintain the privacy of your Protected Health Information (“PHI”), which includes any information that identifies or could be used to identify you.

This Notice explains:

  • Our legal duties and privacy practices
  • How we may use and disclose your PHI
  • Your rights regarding your PHI

YOUR RIGHTS

You have the following rights regarding your PHI. To exercise any of these rights, submit a written request to the Practice at the address listed below.

1. Right to Inspect and Copy PHI

  • You may request a copy (electronic or paper) of your PHI.
  • A reasonable fee may apply.
  • Your request may be denied if access could endanger your life or someone else’s safety.
  • You have the right to request a review of such a denial.

2. Right to Amend PHI

  • You may request corrections to inaccurate or incomplete PHI.
  • Requests must be submitted in writing with a reason.
  • If denied, you will receive a written explanation and may submit a statement of disagreement.

3. Right to Request Confidential Communications

  • You may request that we contact you in a specific way (e.g., phone, email, mail).
  • We will accommodate all reasonable requests.

4. Right to Request Restrictions

  • You may request limits on how your PHI is used or shared for treatment, payment, or operations.
  • We are not required to agree if it impacts your care.
  • If you pay out-of-pocket in full, you may request that we not share that information with your insurer.
  • You may restrict sharing with family or friends by specifying details in writing.

5. Right to an Accounting of Disclosures

  • You may request a list of disclosures of your PHI.
  • One request per 12 months is free; additional requests may incur a fee.

6. Right to Receive a Copy of This Notice

  • You may request a paper copy at any time, even if you agreed to electronic delivery.

7. Right to Appoint a Representative

  • A legal guardian or someone with medical power of attorney may act on your behalf.

8. Right to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with:

Birch Grove Mental Health
10 Chestnut Dr., Unit M
Bedford, NH 03110-5555

238 Littleton Rd, Suite 207A
Westford, MA, United States

Juliana S. Pires, PMHNP
Phone: 617-600-4506

Or with the U.S. Department of Health and Human Services:

We will not retaliate against you for filing a complaint.

9. Right to Opt Out of Fundraising Communications

  • You may request not to receive fundraising communications.

OUR USES AND DISCLOSURES

1. Routine Uses of PHI

We may use and share your PHI without written authorization for:

Treatment

  • Sharing information with healthcare providers involved in your care
  • Example: A doctor consulting about your mental health treatment

Healthcare Operations

  • Managing operations, improving care, and contacting you
  • Example: Appointment reminders

Payment

  • Billing and collecting payment from insurers or third parties
  • Example: Sharing information with your insurance provider

2. Uses Without Authorization or Opportunity to Object

We may disclose PHI without your consent for:

Public Health and Safety

  • Disease prevention
  • Product recalls
  • Reporting adverse medication reactions

Government and Oversight

  • Compliance audits and investigations
  • Reporting abuse, neglect, or domestic violence
  • Preventing serious threats to health or safety

Legal and Law Enforcement

  • Compliance with laws
  • Court orders or subpoenas
  • Law enforcement investigations
  • National security and intelligence activities
  • Workers’ compensation claims

Other Situations

  • Coroners and funeral directors
  • Organ donation
  • Approved research
  • Inmate care
  • Business associates performing services on our behalf

3. Uses With Opportunity to Object

Unless you object, we may share PHI:

  • With family, friends, or others involved in your care
  • When it is in your best interest and you are unable to communicate your preference

4. Uses Requiring Written Authorization

We must obtain your written permission for:

  • Marketing purposes
  • Sale of PHI
  • Use of psychotherapy notes

You may revoke your authorization at any time in writing.

OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your PHI
  • We must follow the terms of this Notice
  • We will comply with stricter state or federal laws when applicable
  • We reserve the right to update this Notice; updated versions apply to all PHI
  • We will notify you in the event of a data breach involving your PHI

EFFECTIVE DATE

This Notice is effective as of January 1, 2019.