NOTICE OF PRIVACY PRACTICES
This notice describes how your clinical information is protected, how it can potentially be used or disclosed, and how you may access this information. As part of the Standard of Care in this field, I am required to provide you with this documentation regarding your Personal Health Information (PHI), how it is protected, and that I must notify you if a breach of your PHI occurs. If the terms of this notice change, the changes will apply to the information I have about you and a new Notice will be available upon request. With the exceptions listed below, I will only use and disclose your PHI with written Authorization and it is your right to revoke such authorization at any time by giving me written notice of your revocation.
CERTAIN USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZATION
Uses and disclosures relating to treatment, payment, or health care operations do not always require your written consent, though in most cases I will make you aware if I intend or need to make such disclosures. Stated below are the circumstances in which I may use and disclose your PHI without authorization each time.
1) For your treatment. I can use and disclose your PHI to treat you, which may include disclosing or consulting with another health care professional. For example, in order to better coordinate care, I may discuss PHI with your physician or another mental health professional with whom you are working or have worked, and I will ask for a formal authorization from you to do so before I contact or have a conversation regarding your PHI.
2) To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I may need to send your PHI to a management company or authorized agent with whom you have asked me to communicate with respect to payment in order to get paid for the health care services that I have provided to you, although my preference is to obtain a formal Authorization from you to do so.
3) For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to this practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.
ADDITIONAL USES AND DISCLOSURES NOT REQUIRING YOUR AUTHORIZATION
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
1) If disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2) For public healthy activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3) For health oversight activities, including audits and investigations.
4) For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5) For law enforcement purposes, including reporting crimes occurring on my premises. 6) To coroners or medical examiners, when such individuals are performing duties as authorized by the law.
7) Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or helping to ensure the safety of those worthing within or housed in correctional institutions.
8) For workers compensation purposes.
9) Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me or to tell you about treatment alternatives or other health care services or benefits that I offer.
Please note that unless prohibited by law, I will always do my best to advise you as to any such disclosures as maintaining your privacy is of utmost importance to me.
CERTAIN USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
- 1) Psychotherapy Notes. I am required by law to keep progress notes as defined in 45 CFR §164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
◊ For my use in treating you.
◊ For my use in training or consulting about your case to help improve my therapeutic skills.
◊ For my use in defending myself in legal proceedings instituted by you.
◊ For use by the Secretary of Health and Human Services to investigate HIPAA compliance.
◊ Required by law and the use or disclosure is limited to the requirements of such Law.
◊ Required by law for certain health oversight activities pertaining to the originator of the profess notes.
◊ Required by a coroner who is performing duties authorized by the law.
◊ Required to help avert serious threat to the health and safety of others.
2) Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3) Sale of PHI. As a psychotherapist I will not sell your PHI in the regular course of my business.
USES AND DISCLOSURES TO WHICH YOU MAY OBJECT
Disclosures to Family, Friends, or Others: I may provide PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
YOUR RIGHTS REGARDING PHI
You have the following rights with respect to your PHI:
1. The Right to Request Limits on Uses and Disclosures of your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care
operations purposes. I am not required to agree to your request, and I may say “no” If I believe it would negatively impact or affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for in Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you I will provide you with a copy of your record, or a
summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so. I may choose to discuss said medical record with you in person if I feel releasing it to you without
discussion may cause you harm. I may also have an agreed to outside therapist review said medical record to make a determination as to whether releasing said medical record is in your best interests
4. The Right to Choose How I send Your PHI to you. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years
unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of the Notice, and you have the right to get a copy of this notice by e-mail. Even if you have agreed to receiving this notice via e-mail, you also have the right to request a paper copy of it.
HOW TO COMPLAIN ABOUT PRIVACY PRACTICES
If you think I may have violated your privacy rights, you may file a complaint with myself or you may also file a complaint with the Board of Behavioral Sciences, citing my LMFT #131312.
Complaints may also be received by the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave., S.W., Washington, D.C., 20201; Calling (877) 696-6775; or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
Please know that I will not take action against you if you file a complaint about my privacy practices.
Effective Date of This Notice: This notice went into effect on November 1, 2020.
