Forms - Planillas

Effective Date: 06/27/2025

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

AGUAS-Latino Counseling Services is committed to protecting the privacy of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by AGUAS-Latino Counseling Services for the purposes of:

• Treatment: We may use or disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes consultation with other health care providers. For example, we may disclose your PHI to a psychiatrist or primary care physician if it is necessary to coordinate your care.

• Payment: We may use and disclose your protected health information to obtain payment for services we provide to you. This may include billing other third-party payer. For example, we may submit requests for payment that include information about the services you received, your diagnosis, and other relevant information.

• Health Care Operations: We may use and disclose your protected health information for our health care operations, which include activities such as quality assessment, employee review, training of students, licensing, and conducting or arranging for other business activities. For example, we may use your information to evaluate the quality of our services or to train new staff members.

• Other Permitted Uses and Disclosures: We are permitted or required by law to make certain other uses and disclosures of your protected health information without your authorization. These include:

  • As Required By Law: We will disclose your protected health information when required to do so by federal, state, or local law.

  • Public Health Activities: We may disclose your protected health information to public health authorities for purposes such as preventing or controlling disease, injury, or disability; reporting vital events such as births and deaths; and conducting public health surveillance.

  • Abuse, Neglect, or Domestic Violence: We may disclose your protected health information to appropriate government authorities if we reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only make this disclosure if required or authorized by law, or if you agree to the disclosure.

  • Health Oversight Activities: We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

  • Judicial and Administrative Proceedings: We may disclose your protected health information in response to a court order or subpoena.

  • Law Enforcement: We may disclose your protected health information to law enforcement officials for certain law enforcement purposes, such as identifying or locating a suspect, fugitive, material witness, or missing person.

  • Coroners, Medical Examiners, and Funeral Directors: We may disclose your protected health information to coroners or medical examiners for identification purposes, determining cause of death, or for other duties as authorized by law. We may also disclose your protected health information to funeral directors as necessary to carry out their duties.

  • Organ and Tissue Donation: We may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of facilitating organ or tissue donation and transplantation.

  • Research: Under certain circumstances, we may use and disclose your protected health information for research purposes. All research projects are subject to a special approval process.

  • Military and Veterans: If you are a member of the armed forces, we may release your protected health information as required by military command authorities.

  • National Security and Intelligence Activities: We may disclose your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

  • Correctional Institutions: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your protected health information to the correctional institution or law enforcement official.

  • Workers' Compensation: We may disclose your protected health information as authorized by and to the extent necessary to comply with laws relating to workers' compensation.

  • To Avert a Serious Threat to Health or Safety: We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

2. Uses and Disclosures Requiring Your Written Authorization

Other uses and disclosures of your protected health information that are not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your protected health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your authorization.

3. Your Rights Regarding Your Protected Health Information

You have the following rights regarding your protected health information:

• Right to Inspect and Copy: You have the right to inspect and copy your protected health information that is maintained by AGUAS-Latino Counseling Services. This right is subject to certain limitations. To inspect and copy your protected health information, you must submit your request in writing to the Privacy Officer (see contact information below).

• Right to Amend: If you believe that your protected health information is inaccurate or incomplete, you have the right to request that we amend the information. To request an amendment, you must submit your request in writing to the Privacy Officer, including the reason(s) why you believe the information is inaccurate or incomplete. We may deny your request if it is not in writing or does not include a reason to support the request.

• Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your protected health information that we have made. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer, specifying the time period for the accounting.

• Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or if required by law. To request a restriction, you must make your request in writing to the Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.

• Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer, specifying how or where you wish to be contacted. We will accommodate all reasonable requests.

• Right to a Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of this notice, please contact the Privacy Officer (see contact information below).

4. Our Responsibilities

AGUAS-Latino Counseling Services is required to:

• Maintain the privacy of your protected health information.

• Provide you with this notice of our legal duties and privacy practices with respect to your protected health information.

• Follow the privacy practices that are described in this notice.

• Notify you if a breach occurs that may have compromised the privacy or security of your information.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

5. Complaints

If you believe that your privacy rights have been violated, you may file a complaint with AGUAS-Latino Counseling Services or with the Secretary of the Department of Health and Human Services. To file a complaint with AGUAS-Latino Counseling Services, please submit your complaint in writing to the Privacy Officer (see contact information below). You will not be penalized for filing a complaint.

6. Contact Information

If you have any questions about this notice or your privacy rights, please contact:

Privacy Officer AGUAS-Latino Counseling Services 120 Falcon Drive, Suite 6 Fredericksburg, VA 22408 (540) 372-7211

© 2025 by L.A. Gonzalez Powered and secured by Wix