Effective Date
This Release of Information is effective as of June 07, 2024.
At Best Fit Counseling & Psychiatry (“we,” “our,” “us”), we understand the importance of your privacy and the confidentiality of your personal health information. This Release of Information (ROI) page explains the conditions under which we may share your health information and the process for you to authorize such disclosures.
I. What is a Release of Information?
A Release of Information (ROI) is a document that allows us to share your personal health information (PHI) with specified individuals or entities. This is typically used to coordinate care, transfer medical records, or communicate with other health care providers.
II. When We May Release Information
We may release your health information under the following circumstances:
- With Your Authorization: We will share your information only with your explicit consent, which can be given by signing a Release of Information form.
- For Treatment Purposes: To coordinate your care with other health care providers involved in your treatment.
- For Payment Purposes: To bill and obtain payment from health insurance companies or other entities.
- For Health Care Operations: To manage our practice and ensure the quality of care provided.
- As Required by Law: In compliance with federal, state, or local laws and regulations.
- In Case of Emergency: When necessary to prevent serious harm or when you are unable to give consent due to a medical emergency.
III. How to Authorize the Release of Information
To authorize the release of your health information, please follow these steps:
- Obtain the Form: You can request a Release of Information form from our office or download it from our website.
- Complete the Form: Provide all required information, including your name, date of birth, the specific information to be released, the purpose of the disclosure, and the recipient’s details.
- Sign the Form: Sign and date the form to give your consent. If you are a legal representative, include your relationship to the patient and provide any necessary documentation.
- Submit the Form: Return the completed form to our office via mail, fax, or in person.
IV. Your Rights
You have the following rights regarding the release of your health information:
- Right to Revoke: You can revoke your authorization at any time by submitting a written request to our office. Revocation will not affect any disclosures made before the revocation was received.
- Right to Limit: You can specify the type of information to be disclosed and set limitations on the scope of the release.
- Right to Access: You can request a copy of the information disclosed through a Release of Information.
V. Contact Information
If you have any questions or need assistance with the Release of Information process, please contact us at:
info@bestfitcounseling.org
VI. Acknowledgment
By submitting a Release of Information form, you acknowledge that you understand the purpose and scope of the disclosure and consent to the release of your health information as specified in the form.