NOTICE OF PRIVACY PRACTICES

MTM Psychiatry
Mara T. Minasian, MSN, PMHNP-BC
5335 W. 48th Ave., Ste. 500, Denver, CO  80212
Phone: (720) 254-1398 • Fax: (949) 703-8795
info@mtmpsychiatry.com • www.mtmpsychiatry.com

This notice describes how medical and mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

MTM Psychiatry believes it may be a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) and thus provides its clients with this Notice of Privacy Practices and is required to comply with the procedures and protocols listed herein. If MTM Psychiatry is determined not to be a covered entity under HIPAA, it will still follow this Notice of Privacy Practices regarding use and disclosure of protected health information; however, the client may not be entitled to the rights set forth in the “Your Rights as a Client” section.

MTM Psychiatry is required by law to maintain the privacy of protected health information (“PHI”) and to provide patients with notice of our legal duties and privacy practices with respect to PHI. MTM Psychiatry is required by law to promptly notify you of any breach that may have occurred and/or that may have compromised the privacy or security of your PHI.

MTM Psychiatry is a mental health practice that provides mental health services. MTM Psychiatry works to provide the best assessments, diagnoses, medication management, psychotherapy, and treatment planning options to its clients. MTM Psychiatry is prohibited from releasing any client information to anyone outside immediate staff, employees, interns, and/or volunteers except in limited circumstances in accordance with this Notice of Privacy Practices. Discussions or disclosures of PHI within the practice are limited to the minimum necessary that is needed for the recipient of the information to perform his/her job. Please review this Notice of Privacy Practices.

It is MTM Psychiatry’s policy to:

  1. Fully comply with the requirements of the HIPAA General Administrative Requirements and Privacy and Security Rules.

  2. Provide every client who receives services with a copy of this Notice of Privacy Practices.

  3. Ask the client to acknowledge receipt when given a copy of this Notice of Privacy Practices.

  4. Take measures to maintain the confidentiality of all client records transmitted by facsimile.

  5. Obtain from each client a signed Authorization for Release of Protected Health Information form when required. 

MTM Psychiatry is required to follow all state and federal statutes and regulations including Federal Regulation 42 CFR Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR Parts 142, 160, 162, and 164, governing testing for and reporting of TB, HIV/AIDS, Hepatitis, and other infectious diseases, and maintaining the confidentiality of PHI.

PHI refers to any information that we create or receive, and relates to an individual’s past, present, or future physical or mental health or conditions and related care services or the past, present, or future payment for the provision of health care to an individual, and identifies the individual or there is a reasonable basis to believe the information can be used to identify the individual. PHI includes any such information described above that we transmit or maintain in any form, including Psychotherapy Notes. HIPAA and federal law regulate the use and disclosure of PHI when transmitted electronically.

YOUR RIGHTS AS A CLIENT

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your mental health record: You can ask to see or get an electronic or paper copy of your mental health record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee to fulfill your request. If we deny your request, in whole or in part, we will let you know why in writing and whether you have the option of having the decision reviewed by an independent third-party.

Ask us to correct your mental health record: You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communication: You can ask us to contact you in a specific way or by a specific means (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Please review MTM Psychiatry’s Consent for Communication of Protected Health Information via Unsecure Transmissions. You are not required to “opt in” to receive communications electronically as set forth in the Consent for Communication of Protected Health Information via Unsecure Transmissions. If you choose not to “opt in” to receive electronic communications, we will not communicate with you via electronic means.

Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Request additional restrictions: You have the right to request additional restrictions on the use or disclosure of your mental health information. However, we do not have to agree to that request, and there are certain limits to any restriction. Ask us if you would like to make a request for any restriction(s).

Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated: You can file a complaint if you feel we have violated your rights by contacting us using the contact information at the top of this form. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. You may also file a complaint with the Colorado Department of Regulatory Agencies, Division of Professions and Occupations, Mental Health Section; 1560 Broadway, Suite 1350, Denver, CO, 80202; (303) 894-2291; DORA_Mentalhealthboard@state.co.us. Please note that the Department of Regulatory Agencies may direct you to file your complaint with the U.S. Department of Health and Human Services Office for Civil Rights listed above and may not be able to take any action on your behalf.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A use of PHI occurs within a covered entity (i.e., discussions among staff regarding treatment). A disclosure of PHI occurs when MTM Psychiatry reveals PHI to an outside party (i.e., MTM Psychiatry provides another treatment provider with PHI, or shares PHI with a third party pursuant to a client’s valid written authorization).

MTM Psychiatry may use and disclose PHI, without an individual’s written authorization, for the following purposes:

  1. Treatment: Using and disclosing your PHI by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members, coverage arrangements during your psychiatric provider’s absence, scheduling appointments, and sending appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

  2. Payment: Using and disclosing your PHI so that MTM Psychiatry can receive payment for the treatment services provided to you, such as making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.

  3. Health Care Operations: Using and disclosing your PHI to support MTM Psychiatry’s business operations which may include but not be limited to: quality assessment activities, licensing, audits, and other business activities.

  4. Business Associates: MTM Psychiatry may enter into contracts with business associates to provide billing, legal, auditing, and practice management services that are outside entities. In those situations, PHI 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 privacy of the PHI released to them.

Uses and disclosures for payment and health care operations purposes are subject to the minimum necessary requirement. This means that MTM Psychiatry may only use or disclose the minimum amount of PHI necessary for the purpose of the use or disclosure (i.e., for billing purposes MTM Psychiatry would not need to disclose a client’s entire medical record to receive reimbursement. MTM Psychiatry would likely only need to include a service code and/or diagnosis, etc.). Uses and disclosures for treatment purposes are not subject to the minimum necessary requirement.

Confidentiality of client records and substance abuse client records maintained are protected by federal law and regulations. It is MTM Psychiatry’s policy that a client must complete an Authorization for Release of Protected Health Information form prior to disclosing health information to another individual and/or entity for any purpose, except for treatment, payment, or health care operations in accordance with this Notice of Privacy Practices. Other than for treatment, payment, or health care operations purposes, MTM Psychiatry is prohibited from disclosing or using any PHI outside of or within the organization, including disclosing that the client is in treatment, without written authorization, unless certain exceptions arise, including: 

  1.  As Required by Law: PHI may be disclosed in compliance with other state and/or federal laws and regulations.

  2. Public Health Activities: PHI may be disclosed to public health authorities for public health activities, such as preventing or controlling disease. We may disclose information about communicable diseases as authorized by law.

  3. Abuse, Neglect, or Domestic Violence: PHI may be disclosed to public health authorities regarding abuse or neglect as required by law. For example, a minor or elderly client reports having been abused or there is reasonable suspicion that abuse has taken or will take place.

  4. Health Oversight Activities: PHI may be disclosed to health oversight agencies for authorized activities, including audits and investigations.

  5. Judicial and Administrative Proceedings: PHI may be disclosed in response to a valid court or administrative order.

  6. Law Enforcement Purposes: PHI may be disclosed for law enforcement purposes under certain conditions, such as responding to court orders or identifying suspects.

  7. Coroners, Medical Examiners, and Funeral Directors: PHI may be disclosed to coroners, medical examiners, and funeral directors to carry out their duties.

  8. Organ and Tissue Donation: PHI may be disclosed to facilitate organ and tissue donation requests.

  9. Research: PHI may be used for research purposes when approved by an institutional review board.

  10. Threat to Health or Safety: PHI may be disclosed to prevent or lessen serious and imminent threats to health or safety. For example, client commits or threatens to commit a crime either at MTM Psychiatry’s office or against any person who works for MTM Psychiatry; client is planning to harm another person, including but not limited to the harm of a child or at-risk elder; or client is imminently dangerous to self or others.

  11. Essential Government Functions: PHI may be disclosed for military or national security purposes.

  12. Workers’ Compensation: PHI may be disclosed for workers’ compensation or similar programs.

The above exceptions are subject to several requirements under the Privacy Rule, including the minimum necessary requirement and applicable federal and state laws and regulations. See 45 CFR § 164.512. Before using or disclosing PHI for one of the above exceptions, MTM Psychiatry’s staff must consult its Privacy Officer (Mara T. Minasian, MSN, PMHNP-BC) to ensure compliance with the Privacy Rule. Violation of these federal and state guidelines is a crime carrying both criminal and monetary penalties. Suspected violations may be reported to appropriate authorities, as listed above in the “Client Rights” section, in accordance with federal and state regulations. Know that MTM Psychiatry will never market or sell your personal information without your permission.

Certain categories of information have extra protections by law and thus require special written authorizations for disclosures, including:

  • Psychotherapy Notes: MTM Psychiatry may keep and maintain “Psychotherapy Notes,” which may include but are not limited to notes MTM Psychiatry makes about your conversation during a private, group, joint, or family counseling session, which are kept separately from the rest of your record. These notes are given a greater degree of protection than PHI. These are not considered part of your “client record.” MTM Psychiatry will obtain a special authorization before releasing your Psychotherapy Notes.

  • HIV/AIDS Information: Special legal protections apply to HIV/AIDS-related information. MTM Psychiatry will obtain a special written authorization from you before releasing information related to HIV/AIDS.

  • Substance Use Disorder Information: Special legal protections apply to substance use disorder-related information. MTM Psychiatry will obtain a special written authorization from you before releasing information related to substance use disorders.

You may revoke all such authorizations to release information (PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing and signed by you. You may not revoke an authorization to the extent that: 1) MTM Psychiatry has relied on that authorization, or 2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.

As a covered entity under the Privacy and Security Rules, MTM Psychiatry is required to reasonably safeguard PHI from impermissible uses and disclosures. Safeguards may include, but are not limited to the following:

  1. Not leaving test results unattended where third parties without a need to know can view them.

  2. Any PHI received as an employee, intern, or volunteer about a client or potential client may not be used or disclosed for non-work purposes or with unauthorized individuals. MTM Psychiatry may only use and disclose such PHI as described above.

  3. When speaking with a client about his or her PHI where third parties could possibly overhear, the conversation will be moved to a private area.   

  4. Seeking legal counsel in uncertain situations and/or incidences.

  5. Obtaining a Business Associates Agreement with those third parties that have access to and/or store client information. Some of the functions of the practice 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.

  6. Implementing fax security measures.

  7. Obtaining your consent prior to sending any PHI by unsecure electronic transmissions.

  8. Providing information on our electronic recordkeeping if requested. 

YOUR CHOICES

For certain health information, you can tell MTM Psychiatry (verbal authorization) your choices about what we share. If you have a clear preference for how MTM Psychiatry shares your information in the situations described below, tell us what you want us to do, and we will follow your instructions. MTM Psychiatry may request you sign a separate document if you authorize it to share certain PHI. You may revoke that authorization at any time for future disclosure.

In these cases, you have both the right and the choice to tell MTM Psychiatry to:

  • Share information with your family, close friends, or others involved in your care.

  • Share information in a disaster relief situation.

  • Include your information in a hospital directory.

If you are not able to tell MTM Psychiatry your preference (for example, if you are unconscious), MTM Psychiatry may go ahead and share your information if MTM Psychiatry believes it is in your best interest and for your care/treatment. MTM Psychiatry may also share your information when needed to lessen a serious and imminent threat to public health or safety.

In these cases, we never share your information unless you give us written permission:

  • Marketing purposes

  • Sale of your information

  • Most sharing of psychotherapy notes

Changes to the Terms of this Notice: MTM Psychiatry reserves the right to change the terms of this notice, and the changes will apply to all the protected health information MTM Psychiatry maintains. The new notice will be available upon request, in MTM Psychiatry’s office, and on its website.

Effective Date: This notice is effective July 1, 2025.

For more information: If you have any questions or would like more information about MTM Psychiatry’s Notice of Privacy Practices, please contact us using the contact information at the top of this form. Additionally, for more information you may visit www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.