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.
I. 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, below are some definitions and examples. Not every particular use or disclosure in every category will be listed.
· “Protected health information (PHI)” refers to information in your health record that could identify you. In this practice, your health record may be maintained in paper and/or electronic form. Examples of what may be included in this record include the following: dates of our sessions, reasons you came to treatment, description of concerns/problems, relevant history, diagnoses, treatment plan, progress notes, test results, records or reports from other providers, information about medications you took or are taking, legal matters, and billing and insurance information. There may be other kinds of information that go into your health records here.
· “Treatment, Payment and Health Care Operations”
- Treatment refers to my providing, coordinating, or managing your mental health care and other services related to your mental health care. Examples of treatment include individual, couples, or group psychotherapy sessions, phone consultations or phone therapy sessions, or my consultation with another health care provider, such as your psychiatrist, family physician, or another psychologist. As another example, I may use or disclose your protected health information to remind you that you have an appointment for health care services. Reminders may include written notifications distributed via the US Postal system, verbal telephone communications and/or messages, or electronic mail messages.
- Payment occurs when I obtain reimbursement for your mental health care. For example, I may disclose your PHI to your health insurer to obtain reimbursement for your mental 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, and case management and care coordination.
· “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
· “Consent" is a general permission that allows me to use and disclose your health care information for routine purposes of treatment, payment and operations.
II. 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” is 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 may make about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI and/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.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse: If I have reasonable cause, on the basis of my professional judgment, to suspect abuse of children with whom I come into contact in my professional capacity, I am required by law to report this to the Pennsylvania Department of Public Welfare.
· Vulnerable or Older Adult Abuse: If I have reasonable cause to believe that a vulnerable or older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), I may report such to the local agency which provides protective services.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release the information without your written consent, 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. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: If you express a serious threat, or intent to kill or seriously injure yourself or an identified or readily identifiable person or group of people, and I determine that you are likely to carry out the threat, I must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
· Health Oversight: Pennsylvania law requires that I report misconduct by a health care provider of my own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report that you are in treatment if I believe that your condition places the public at risk. Pennsylvania Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Required by Federal Law: This office is required by Federal law to disclose your protected health information to the U.S. Department of Health and Human Services upon request for the purpose of determining whether this medical practice is in compliance with the Federal Privacy Standards.
· Law Enforcement Purposes: I may be required to release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.
· For Public Health Activities: I may be required to disclose some of your PHI to agencies that investigate diseases or injuries.
· Relating to Decedents: I may be required to disclose PHI to coroners, medical examiners, or funeral directors, and to organizations relating to organ, eye, or tissue donations or transplants.
· For Specific Government Functions: I may be required to disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment. I may disclose your PHI to workers’ compensation and disability programs, to correctional facilities if you are an inmate, or to other government agencies for national security reasons.
· Workers’ Compensation: If you file a workers’ compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
IV. Patient's Rights and Psychologist's Duties
· 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 at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I call you at home, and not at work, to schedule or change an appointment.)
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the 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 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 written 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.
· 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 and to make the changed policies and practices effective for all PHI I keep.
· If I revise my policies and procedures, a new copy will be made available in the waiting room. I also will have copies of the current notice of privacy practices available on request.
V. 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 Valerie R. Wilson, Ph.D. at 267-634-1719.
If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to Valerie R. Wilson, Ph.D., at 255 South 17th Street, Suite 1307, Philadelphia, PA 19103.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above 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.
VI. Effective Date
The effective date of this notice is September 19, 2012.
· If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
· If you are self-pay, then you may restrict the information sent to insurance companies.
· Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
Date of Addendum: September 23, 2013