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.

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

We 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 we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another counselor.

– Payment is when we obtain reimbursement for your healthcare.  Examples of payment are when we 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 our practice.  Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.

1. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.  In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information.  We will also need to obtain an authorization before releasing your progress notes. “Progress notes” are notes your counselor has made about your conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your clinical record.  These notes are given a greater degree of protection than PHI.

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

III. Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse – If we have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect, or if we observe a child being subjected to conditions which would reasonably result in abuse or neglect, we must immediately report such information to the appropriate authorities as required by law. We must also report sexual abuse or molestation of a child less than 18 years of age to the appropriate authorities as required by law.  We may also report child abuse or neglect to a law enforcement agency or juvenile office.

• Adult and Domestic Abuse – If we have reasonable cause to suspect that an eligible adult (defined below) presents a likelihood of suffering physical harm or is in need of protective services, we must report such information to the appropriate authorities as required by law.

“Eligible adult” means any person 60 years of age or older, or an adult with a handicap (substantially limiting mental or physical impairment) between the ages of 18 and 59 who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs.

• Health Oversight Activities – The Attorney General’s Office may subpoena records from us relevant to disciplinary proceedings and investigations conducted by state regulating boards.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis or treatment and the records thereof, such information is privileged under state law, and we will not release information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered.  We will inform you in advance if this is the case.

• Serious Threat to Health or Safety – When we judge that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by you on yourself or another person, we must disclose your relevant confidential information to the appropriate professional workers, public authorities, the potential victim, his or her family, or your family.

• Workers’ Compensation – If you file a worker’s compensation claim, we must permit your record to be copied by the State Labor and Industrial Commission or the Division of Worker’s Compensation of the State Department of Labor and Industrial Relations, your employer, you and any other party to the proceedings.

1. Client’s Rights and Psychotherapist’s Duties

Client’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of Protected Health Information. However, we are 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 at alternative locations. (For example, you may not want a family member to know that you are counseling with us. On your request, we will send your bills to another address.) 

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and 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. We may deny your request. On your request, we 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. On your request, we 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 us upon request, even if you have agreed to receive the notice electronically.

Counselor’s Duties:

• We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

• We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

• If we revise our policies and procedures, we will publicly post these changes in our waiting room or notify you of any changes when you arrive for your first appointment following the implementation of changes.

1. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, please contact your therapist to discuss this matter.  If you are still not satisfied that the matter has been resolved, you may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  Understand that should you make a complaint, you are protected from retaliation from the service provider you are making the complaint against. 

1. Effective Date, Restrictions and Changes to Privacy Policy

The effective date of this notice is April 14, 2003.  We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.  We will publicly post the revised notice in our waiting room and or provide you with a revised notice when you arrive for your first appointment following the implementation of changes.