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
medical record
You can ask to see or get an electronic or paper copy of your medical 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.
Ask us to correct your
medical 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
You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Your Rights
Notice of Privacy Practices • Page 1
Your Information.
Your Rights.
Our Responsibilities.
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.
continued on next page
Cornerstone Counseling and
Wellness, LLC.
639 Swedesford Road, Malvern, PA 19355
HIPAA contact: Front Office Supervisor
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.
Get a list of those with
whom we’ve shared
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 complain if you feel we have violated your rights by contacting us
using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human
Services Ofce for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
We will not retaliate against you for filing a complaint.
Notice of Privacy Practices • Page 2
Your Rights continued
Your Choices
For certain health information, you can tell us your choices about what we share. If you
have a clear preference for how we share your information in the situations described below, talk to us. Tell
us what you want us to do, and we will follow your instructions.
In these cases, you have
both the right and choice
to tell us 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
Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are
unconscious, we may go ahead and share your information if we believe it is
in your best interest. We may also share your information when needed to
lessen a serious and imminent threat to 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
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to
contact you again.
Notice of Privacy Practices • Page 3
How do we typically use or share your health information? We typically use or share your health
information in the following ways.
Treat you
We can use your health information and
share it with other professionals who are
treating you.
Example: A doctor treating you
for an injury asks another doctor
about your overall health condition.
Run our
We can use and share your health information
to run our practice, improve your care,
and contact you when necessary.
Example: We use health information
about you to manage your treatment
and services.
Bill for your
We can use and share your health information
to bill and get payment from health plans or
other entities.
Example: We give information
about you to your health insurance
plan so it will pay for your services.
Our Uses and Disclosures
continued on next page
Notice of Privacy Practices • Page 4
How else can we use or share your health information? We are allowed or required to share
your information in other ways – usually in ways that contribute to the public good, such as public health and
research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health
and safety issues
We can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it,
including with the Department of Health and Human Services if it wants to
see that we’re complying with federal privacy law.
Respond to organ and
tissue donation requests
We can share health information about you with organ procurement
Work with a medical
examiner or funeral director
We can share health information with a coroner, medical examiner, or
funeral director when an individual dies.
Address workers’
compensation, law
enforcement, and other
government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security,
and presidential protective services
Respond to lawsuits and
legal actions
We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
We do not operate or manage a hospital directory.
Notice of Privacy Practices • Page 5
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The
new notice will be available upon request, in our office, and on our web site.
Our Responsibilities
This Notice of Privacy Practices applies to the following organizations.
Effective Date of Notice: October 2013
All providers, contractors and employees of Cornerstone Counseling and Wellness, LLC have a (OHCA)
Organized Healthcare Arrangement with all providers, contractors and employees at Mainline Behavioral
Health located at 15 Industrial Blvd, Suite 203, Paoli, PA 19301.
Our Organized Health Care Arrangement (OHCA) is an arrangement or relationship, recognized in the
HIPAA privacy rules, that allows two or more Covered Entities (CE) who participate in joint activities to
share protected health information (PHI) about their shared patients in order to manage and benefit their
joint operations.