Tel: (480) 559-8050

    Fax: (480) 947-3743



Our commitment to your privacy: Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information. The following circumstances may require us to use or disclose your health information: (1) to public health authorities and health oversight agencies that are authorized by law to collect information (2) lawsuits and similar proceedings in response to a court or administrative order (3)If required to do so by a law enforcement official (4)when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat (5) if you are a member of the U.S. or foreign military forces (including veterans) and if required by the appropriate authorities (6) to federal officials for intelligence and national security activities authorized by law (7) to correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official (8) for Workers Compensation and similar programs.

Your rights regarding your health information: You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will accommodate reasonable requests. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure or your health information to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement, except when otherwise required by law, or when the information is necessary to treat you. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept for our practice. You must provide us with a reason that supports your request for amendment. If you believe your privacy rights have been violated, you may file a complaint with our practice, or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, all complaints must be submitted in writing. You will not be penalized for filing a complaint.

© 2011

Benjamin Behavioral Health Services

All rights reserved.