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    EFFECTIVE DATE – November 1, 2019

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  PLEASE REVIEW THIS INFORMATION CAREFULLY.  This notice applies to Insight Behavioral Health Network (IBHN) providers, and the doctors and other healthcare providers contracted through IBHN.

    It is our legal duty and we are required by law to protect the privacy of your information and to notify you of certain breaches of your information.  We are providing this notice so that we can explain our privacy practices.  We will follow the practices described in this notice or the current notice in effect.     We reserve the right to change our policies and notice of privacy practices at any time.  If we should make a significant change in our policies, we will change this notice and post the new notice.  You can also request a copy of our notice at any time.  For more information about our privacy practices or to place a complaint or report a concern or conflict, call the number listed below:


    Trey Ligon, Privacy Officer


    You may also send a written complaint to the United States Department of Health and Human Services if you feel we have not properly handled your complaint.  You can use the contact listed above to provide you with the appropriate address or visit  Under no circumstance will you be retaliated against for filing a complaint.

    We may use health information about you for your treatment purposes, to obtain payment, or for healthcare operations and other administrative purposes.  For example, we may use your information in treatment situations if we need to send your medical record information to a specialist or physician as part of a referral for continuing care.  We will send your health information and other identifying information to Medicare, Medicaid or other health insurance plans for our billing purposes. Your information will be used when processing your medical records for completeness and to compare patient data as part of our efforts to continually improve our treatment methods.  We may disclose your information to our business associates we contract with to provide service on our behalf that requires the use of your health information.  We may share certain information with a person(s) you identify as a family member, relative, friend, or other person that is directly involved in your care or payment for your care, or if it becomes necessary to notify these individuals about your location, general condition, or death.  In addition we may need to disclose medical information about you to an entity assisting in disaster relief efforts so that your family can be notified about your condition, status, and location.

    Under certain circumstances we may be required to disclose your health information without your specific authorization.  Examples of these disclosures are:  requirements by state and Federal laws to report cases of abuse, neglect, or other reasons requiring law enforcement; for public health activities; to health oversight agencies; for judicial and administrative proceedings; for death and funeral arrangements; for organ donation; for special government functions including military and veteran requests, and to prevent serious threat to health or public safety.  We may also contact you after your current visit for future appointment reminders or to provide you with information regarding treatment alternatives or other health related services that may be of benefit to you.

    Most uses and disclosures of psychotherapy notes, those for marketing purposes, and those that constitute a sale of medical information will only be made with your written authorization. We will obtain your written authorization for any other disclosures beyond the reasons listed above.  Do remember, if you do authorize us to release your information, you always have the right to revoke that authorization later.  We will be happy to honor that request except to the extent that we may have already acted.

    As a patient, you have rights regarding how your information can be used and disclosed. These rights include access to your health information.  In most cases, you have the right to look at or receive a copy of your health information.  This may take up to 30 days to prepare and there may be a preparation fee associated with making any copies.  You can ask for an accounting of disclosures.  This is a list of instances in which we have disclosed your information for reasons other than treatment, payment and operations that you have not specifically authorized but that we are required to do by law.  We can provide you one list per year without charge; all additional requests in the same year will be subject to a nominal charge.  If you believe that the information we have about you is incorrect or if important information is missing, you have the right to request that we amend or correct the existing information. There may be some reasons that we cannot honor your request for which you submit a statement of disagreement.  You can also request that your health information be communicated to you at an alternate location or address that is different from the one we received when you were registered.



    With my consent, Insight Behavioral Health Network (IBHN) providers, may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations. The practice provides this form to comply with the Health Information Portability and Accountability Act (HIPAA) of 1996.

    I have the right to review the Notice of Privacy Practices prior to signing this consent. IBHN providers reserves the right to revise its Notice of Privacy Practices at any time.  You ascertain that by your signature that you have reviewed our notice before signing this consent.

    With my consent, IBHN providers may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results and others.

    With my consent, IBHN may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards and patient statements.

    With my consent, IBHN providers may e-mail to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminder cards and patient statements. I have the right to request that IBHN providers restrict how it uses or discloses my protected health information to carry out treatment, payment and healthcare operations.

    However, the practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement.

    By signing this form, I am consenting to IBHN providers to use and disclosure of my protected health information to carry out treatment, payment and healthcare operations.

    I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If l do not sign this consent IBHN providers may condition receipt of treatment.




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    SIGNATURE OF PATIENT OR LEGAL GUARDIAN                                             Date