Clinician: Michelle Tobin, MA, LMHCA, PMP
Business: Sublime Online PLLC
Address: 1404 NE 134th St, Suite 290, Vancouver, WA 98685
Phone: (360) 207-1957 | Fax: (360) 418-0114
Email: michelle@sublime.online
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I understand that health information about you and your healthcare is personal. I am committed to protecting health information about you. This Notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and certain obligations I have regarding the use and disclosure of your health information.
I keep a record of the health care services I provide to you. You may ask me to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so. You may see your record or get more information about it at 1404 NE 134th St, Suite 290, Vancouver, WA 98685.
Protected Health Information:
This Notice applies to protected health information (PHI) created or received by Sublime Online PLLC that identifies you; relates to your past, present, or future physical or mental condition; relates to the care provided; or relates to the past, present, or future payment for your healthcare. For example, PHI includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services.
Your Rights:
When it comes to your protected health information (PHI), you have the right to:
• See and receive an electronic or paper copy of your health information. In most cases, you have the right to review and receive a copy of certain healthcare information, including certain medical and billing records. If you request a copy of the information, then I may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
• Ask for a change or addition to your health information. If you believe that information in your record is incorrect or that important information is missing, then you have the right to request in writing that I make a correction or add information. You must include a reason for the amendment in your request. I am not required to agree to the amendment of your record, but a copy of your request will be added to your record.
• Ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. You must make your request in writing (including email). I will grant all reasonable requests. Your request must specify how or where you wish to be contacted.
• Ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say "no" if it would affect your care. If you pay for a service or healthcare item out-of-pocket in full, then you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say "yes" unless a law requires me to share that information.
• Ask for a list of persons or entities outside of Sublime Online PLLC with whom I have shared your health information. Certain instances will not appear on the list, such as disclosures for treatment, payment, or when you have authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free of charge. Any additional request within the same calendar year requires a processing fee.
• Ask for a paper or electronic copy of this Notice.
• Choose someone to act for you. If you have given medical power of attorney or if someone is your legal guardian, then that person can exercise your rights and make choices about your health information.
• File a complaint if you feel like your privacy rights have been violated. You may file a complaint with Sublime Online PLLC by using the contact information at the top of this document. You may 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 SW, Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.
• Ask for a change or addition to your health information. If you believe that information in your record is incorrect or that important information is missing, then you have the right to request in writing that I make a correction or add information. You must include a reason for the amendment in your request. I am not required to agree to the amendment of your record, but a copy of your request will be added to your record.
• Ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. You must make your request in writing (including email). I will grant all reasonable requests. Your request must specify how or where you wish to be contacted.
• Ask me to limit what I use or share. You can ask me not to use or share certain health information for treatment, payment, or my operations. I am not required to agree to your request, and I may say "no" if it would affect your care. If you pay for a service or healthcare item out-of-pocket in full, then you can ask me not to share that information for the purpose of payment or my operations with your health insurer. I will say "yes" unless a law requires me to share that information.
• Ask for a list of persons or entities outside of Sublime Online PLLC with whom I have shared your health information. Certain instances will not appear on the list, such as disclosures for treatment, payment, or when you have authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free of charge. Any additional request within the same calendar year requires a processing fee.
• Ask for a paper or electronic copy of this Notice.
• Choose someone to act for you. If you have given medical power of attorney or if someone is your legal guardian, then that person can exercise your rights and make choices about your health information.
• File a complaint if you feel like your privacy rights have been violated. You may file a complaint with Sublime Online PLLC by using the contact information at the top of this document. You may 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 SW, Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.
My Responsibilities:
• I am required by law to maintain the privacy and security of your PHI.
• I will let you know promptly if a breach occurs that may have compromised the privacy and security of your health information.
• I must follow the duties and privacy practices described in this Notice and give you a copy of it.
• I will not use or share your information other than as described here unless you give me written permission.
• I will let you know promptly if a breach occurs that may have compromised the privacy and security of your health information.
• I must follow the duties and privacy practices described in this Notice and give you a copy of it.
• I will not use or share your information other than as described here unless you give me written permission.
Use and Disclosure of Your Health Information:
I may use and disclose your protected health information (PHI) for the following reasons:
• Provide treatment. Some examples include, but are not limited to: Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your healthcare treatment and any related services. This may include coordination or management of your healthcare with a third party, consultation, or supervision activities with other healthcare providers, or referral to another provider for healthcare services.
• Payment purposes. Some examples include, but are not limited to: I may use your PHI to prepare claims for payment of services you have received or to communicate with other individuals or agencies to receive payment.
• Maintain healthcare operations. I may use or disclose your PHI to support the business activities of my professional practice, for example, to monitor and improve healthcare services or for authorized staff to perform administrative activities.
• Train staff and students. Staff or students who are in training may assist me with responsibilities.
• Conduct research. An Institutional Review Board (IRB) will review each request to use or disclose your PHI to protect the rights, safety, and welfare of research subjects.
• Contact you for information. Your personal information may be used to contact you to remind you about appointments, provide diagnostic results, inform you about treatment options, or advise you about other health-related benefits and services.
• Consult with business associates. Your health information may be disclosed to individuals or organizations that assist me in my business activities, for example, consultants or attorneys. These business associates are required to protect the confidentiality of your information.
• Provide treatment. Some examples include, but are not limited to: Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your healthcare treatment and any related services. This may include coordination or management of your healthcare with a third party, consultation, or supervision activities with other healthcare providers, or referral to another provider for healthcare services.
• Payment purposes. Some examples include, but are not limited to: I may use your PHI to prepare claims for payment of services you have received or to communicate with other individuals or agencies to receive payment.
• Maintain healthcare operations. I may use or disclose your PHI to support the business activities of my professional practice, for example, to monitor and improve healthcare services or for authorized staff to perform administrative activities.
• Train staff and students. Staff or students who are in training may assist me with responsibilities.
• Conduct research. An Institutional Review Board (IRB) will review each request to use or disclose your PHI to protect the rights, safety, and welfare of research subjects.
• Contact you for information. Your personal information may be used to contact you to remind you about appointments, provide diagnostic results, inform you about treatment options, or advise you about other health-related benefits and services.
• Consult with business associates. Your health information may be disclosed to individuals or organizations that assist me in my business activities, for example, consultants or attorneys. These business associates are required to protect the confidentiality of your information.
Other Uses and Disclosures:
I also use and disclose your information to enhance healthcare services, protect client safety, safeguard public health, ensure compliance with government and accreditation standards, and when otherwise allowed by federal and state law. For example, I provide or disclose information:
• To government oversight agencies with data for health oversight activities authorized by law, such as auditing or licensure.
• To appropriate government agencies when I suspect abuse or neglect, as I am a mandated reporter.
• To appropriate agencies or persons when I believe it necessary to avoid a serious threat to health or safety or to prevent serious harm.
• To law enforcement when required or allowed by law.
• For court order or lawful subpoena.
• To government officials when required for specifically identified functions, such as national security.
• When otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance with my obligations to protect the privacy of your health information.
• To government oversight agencies with data for health oversight activities authorized by law, such as auditing or licensure.
• To appropriate government agencies when I suspect abuse or neglect, as I am a mandated reporter.
• To appropriate agencies or persons when I believe it necessary to avoid a serious threat to health or safety or to prevent serious harm.
• To law enforcement when required or allowed by law.
• For court order or lawful subpoena.
• To government officials when required for specifically identified functions, such as national security.
• When otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance with my obligations to protect the privacy of your health information.
I have to meet many standards set forth by the law before I can share your information for these purposes. For more information, please visit: https://hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html.
Use and Disclosure Requiring Your Authorization:
Other than the uses and disclosures described above, I will not use or disclose your PHI without your written permission. Sublime Online PLLC requires your written authorization for each individual entity for sale of your information, most sharing of psychotherapy notes, and marketing purposes. You can change your mind at any time about how you authorize me to use your PHI unless disclosure is required for me to obtain payment for services already provided, I have otherwise relied on the authorization, or the law prohibits revocation.
In the cases that require your written authorization, you have both the right and choice to give me permission 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 facility directory (but I don’t have a facility directory).
• Contact you for fundraising efforts (but you can tell me not to contact you again).
• 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 facility directory (but I don’t have a facility directory).
• Contact you for fundraising efforts (but you can tell me not to contact you again).
Privacy Officer:
I act as my own Privacy Officer. If you have any questions or need more information about this Notice, please contact Michelle Tobin by calling 360-207-1957, emailing michelle@sublime.online, or sending a secure message via the Sublime Online Client Portal.
Changes to the Terms of this Notice:
I can change the terms of this Notice, and the changes will apply to all information I have about you as well as any information I may receive in the future. The new notice will be available by request, at my office, or on my website. A current version of this Notice is posted at https://sublime.online/notice-of-privacy-practices. For more information about this Notice, please visit https://hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html.
Effective Date of this Notice:
This Notice went into effect on January 25, 2023.