Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. AFTERWARDS FEEL FREE TO ASK ME ANY QUESTIONS YOU HAVE ABOUT IT.

Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent.

To help clarify these terms here are some “definitions:”

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment, and Health Care Operations”

“Treatment” is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

• “Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
• “Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management and care coordination, and peer supervision/consultation
• “Use” applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside my office such as releasing, transferring, or providing access to information about you to other parties.

Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” can also be called a “release of information”: written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes.

“Psychotherapy notes” are notes I have made about our conversation during or following a private, group, joint, or family counseling session. These notes will be kept separate from the rest of your medical record. These notes are therefore given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

You should be aware that when enrolling or signing documents from some insurance companies you might be waving certain rights and allowing access to documents in your record. Also, in order to join your insurance network, many insurance companies require that the therapist agree to full or partial access to PHI. For these reasons, and others, I chose to limit my in-network involvement. I suggest that you contact your insurance company regarding their policies and procedures.

Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances: There might be a need to break confidentiality if you were in medical jeopardy, suicidal, or dangerous to another person. There are laws concerning abuse of children and the elderly that require report to the proper officials. Records subpoenaed for health oversight or certain judicial/administrative proceedings may also be released. Although these exceptions may not arise during your treatment, it is important that you are aware of them. If it is necessary to break confidentiality because of one of these reasons, I will release only information that is relevant in order to provide for your safety, the safety of others, or as is required by law.

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and locations. (For example, you may not want a family member to know you are seeing me. Upon your request, I will send bills to another address.)

Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in my record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and the denial process.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Psychologist’s Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures and you are currently an active client, I will notify you in person. If you are not available, I will notify you by mail.

Questions and Complaints:

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights you may contact the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

Psychologist’s Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures and you are currently an active client, I will notify you in person. If you are not available, I will notify you by mail.