Notice of Privacy Practices
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.
Donna Montgomery, LCSW., RN. provides health services in partnership with other professionals and organizations. I understand that medical information about you is personal and that I am required by law to keep medical information about you private. I create a record of the treatment and services you receive (your chart) to provide quality care and to comply with legal requirements. You can request to look at your chart by simply letting me know. If you believe that information in your chart is incorrect or that important information is missing, you have the right to request a correction by submitting a written request for an amendment. I could deny the request if it is not part of the medical information maintained by me, or if I decide that the chart is already accurate. You can then appeal that decision if you still want the chart amended.
I will give out medical information about you with your prior authorization only for:
- Your treatment
- To obtain payment for treatment
- For health care operations
I may disclose or use your medical information without your prior authorization only for:
- Public health purposes
- For reporting abuse or neglect (required by law)
- Workers' compensation purposes
- Judicial or administrative proceedings
- Serious threat to health or safety
You also have the right to a list of any instances where I disclose medical information about you for reasons other than treatment or payment.
If you have any questions, or you think your privacy rights may have been violated, please let me know. You may also contact the Kentucky Board of Social Work, PO Box 1360, Frankfort, Ky. 40602 or send a written complaint to the Secretary of the US. Department of Health and Human Services.