HIPAA Notice of Health Information
Privacy Practices

In 1996, a law was passed entitled “the Health Insurance Portability and Accountability Act (HIPAA).” This law sets out new standards for the confidentiality and security of health data. Health data includes your medical records as well as your billing records. This notice may seem overwhelming, please review it carefully and let me know if you have any questions.

Your privacy is of the utmost importance to me, and as such, I am committed to responsibly and ethically handing your health information. In addition to maintaining the privacy of your confidential health information, I am required by law to give you a notice of my privacy practices. Unless you give me explicit permission, I will only disclose your information when I am legally or ethically required to do so.

This Notice of Health Information Privacy Practices describes the health information I collect, and how and when I use or disclose that information. It also describes your rights as they relate to your protected health information and how you can obtain access to that information. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. If you have any questions about your confidentiality at any time during our work together, you have the right to ask me.

I. Understanding Your Health Record/Information

Each time you visit me, a record of your visit is made. Typically, this record contains describes the services provided to you, dates of our sessions, your diagnosis, treatment, functional status, symptoms, prognosis and progress, any psychological testing results, and plan for future care or treatment. This information, often referred to as your “protected health information” or “PHI”, serves as a:

• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided, should you choose to pursue reimbursement.
• For teaching and training other health care professionals; medical or psychological research
• A source of information for public health officials charged with improving the health care in this area of the country
• A tool with which I can assess and continually work to improve the services rendered and the outcomes achieved

Understanding what is in your record and how your protected health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. Although your health record is the physical property of my practice, the information belongs to you and the law gives you rights to know about your PHI (see section on Your Health Information Privacy Rights).

II. Responsibilities of my practice

Legally, I am required to:

• Maintain the privacy of your health information
• Provide you with this form explaining legal duties and privacy practices with respect to information I collect and maintain about you
• Abide by the terms of this notice
• Notify you if I am unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information to you by alternative means or at alternative locations

I reserve the right to change my privacy practice notice, and to make the new provisions effective for all protected health information I maintain. Should my information practices change, I will provide you with a copy of the revised notice. I will not use or disclose your health information without your authorization, except as described in this notice. I will also discontinue to use or disclose your health information after I have received a written revocation of the authorization according to the procedures included in the authorization.

Except in some special circumstances, when I use your health information or disclose it to others, I share only the minimum necessary PHI needed for those other people to do their jobs. Mainly, I will use and disclose your PHI for routine purposes to provide for your care, and I will explain more about these below. For other uses, I must tell you about them and ask you to sign a written authorization form. However, the law also says that there are some uses and disclosures that do not need your consent or authorization.

I will use and disclose your PHI for many different reasons. For some of these uses, I will need your prior written authorization. For others, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

III. How I may use and disclose your PHI without consent

In order for me to provide the most proper and ethical treatment, you must agree to let me collect your PHI. Therefore, you must sign the consent form before I begin to treat you. If you do not agree and consent, then I am not allowed to treat you. The following section describes the circumstances in which I may disclose your health information. In every instance, I make all uses and disclosures according to our privacy policies and the law.

• For Treatment/Evaluation: I may use health information about you to provide you with psychotherapy or evaluation services. I may disclose PHI about you to your primary care physician if it is required by your insurance or managed company. I only do this when required and/or necessary for your treatment. Also, I may disclose health information about you to a referring psychiatrist if you may require a psychotropic evaluation or medication. From time to time, it is helpful for me to consult with other professionals regarding your care. In such events, our consultants are also legally bound by the privacy practice policies.
• For Payment: With your written permission, I may use and disclose your PHI for payment purposes. I may need to give your health insurance plan information about treatment you received at my practice so that your health plan will pay me or repay you for any services that you paid for. I may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for the treatment.
• Health Care Operations: I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you have received from me, or to evaluate the performance of the treatment I have provided to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my healthcare practice.
• Other Uses and Disclosures in Health Care:
  • Medical Emergency: I may use or give your health information to help you in a medical emergency or if you become incapacitated.
  • Appointment Reminders: I may use and disclose your PHI to reschedule or remind you of appointments for treatment or other care.
  • Treatment Alternatives and Other Benefits or Services: I may use and disclose your PHI to tell you about or recommend possible treatments, alternatives, health-related benefits, or services that may be helpful to you.

IV. Uses and Disclosures Requiring Authorization

Except for the situations listed above, I must have your written permission to disclose any of your health information on an authorization form. I do not expect to do this very often. You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. Your permission will end when I receive the signed form, or when I have acted on your request. I cannot take back any information I have already disclosed or used with your permission.

V. Uses and Disclosures with Neither Consent nor Authorization

Due to ethical standards, there are some situations in which I must use or disclose PHI without your consent or authorization. The following section describes these circumstances:

• Child Abuse: If I have reasonable suspicion that a child (any child, not just your own) is being, or has recently been, subjected to abuse or neglect, I must contact Child Protective Services.
• Vulnerable Adult Abuse: If I have reason to believe that an older adult or vulnerable individual (who is protected by state law) has been abused, neglected, or exploited, I must report this information to the appropriate authorities.
• Health Oversight Activities: I may disclose PHI regarding you to a health oversight agency for oversight activities authorized by law, including licensure and disciplinary actions.
• Law Enforcement: I may give certain health information to law enforcement officials to investigate a crime or criminal.
• Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis, and treatment, and the records thereof, such information is privileged under state law and cannot be released without your authorization or a court order. Information about all other psychological services is also privileged and cannot be released without your authorization or a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. The privilege does not apply when you are being evaluated by a third party or when the evaluation is court ordered. You must be informed in advance if this is the case.
• Serious Threat to Health or Safety: If you communicate to your practitioner a specific threat of imminent harm against another individual or if I believe that there is a clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures believed to be necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures considered necessary to protect you from harm. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying law enforcement agencies, or 3) seeking your hospitalization in an inpatient psychiatric facility to be evaluated, or 4) contacting appropriate third parties in a position to prevent or avert the harm.
• Worker’s Compensation: I may disclose PHI regarding you as authorized by and to the extent necessary to comply with the laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.
• Public Health Activities: I may disclose some of your PHI to agencies that investigate diseases or injuries.
• Relating to Decedents: I may disclose your PHI to coroners, medical examiners, or funeral directors, and to organizations relating to organ, eye, or tissue donations or transplants.
• Specific Government Functions: I may disclose the PHI of military personnel and Veterans to government benefit programs relating to eligibility and enrollment, I may disclose PHI to disability programs, to correctional facilities if you are an inmate, or to other government agencies for national security reasons.

VI. Use and Disclosures Where You Have the Opportunity to Object

I can share some information about you with your family or close others. I will only share information with those involved in your care and anyone else you choose, such as close friends or clergy. I will ask you which persons you want me to tell, and what information you want me to tell them about your condition or treatment. Should you want me to share any information with these individuals, I will likely ask you to complete a release of information form.

If an emergency situation arises in which I am unable to ask whether you disagree, I can share information if I believe that doing so is what you would have wanted, and if I believe it will help you if the information is shared. If I do share information, in an emergency, I will tell you as soon as possible. In most cases, the opportunity to consent may be obtained retroactively in emergency situations.

VII. Your Health Information Privacy Rights

• Right to Request Restrictions: You have the right to request restrictions on the use and disclosure of your PHI to carry out my treatment, payment, or healthcare operations. However, I am not required to agree to a restriction you request. For example, you have the right to restrict certain disclosures of PHI to a health plan if you pay out-of-pocket in full for the full healthcare service. If I do accept your request, I will put that in writing and abide by them, except in emergency situations.
• 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, if you do not want a family member to know that you are seeing me, I can send bills to another address upon your request. You may also request that I contact you only at home or at work. To request alternative communication, you must specify your request in writing, specifying how or where, you wish to be contacted.
• 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. Upon your request, I will discuss with you the details of the request for access process. You may incur a reasonable fee for costs of copying, mailing, and/or other supplies associated with your request. This right to inspect is not absolute. I am permitted to deny access for specified reasons. For instance, you do not have this right of access with respect to my “psychotherapy notes.” The term “psychotherapy notes” means notes recorded (in any form) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, or family counseling session, and that are separated from the rest of the individual’s medical (includes mental health) record. The term excludes session start and stop times, the modalities and frequencies of treatment furnished, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
• Right to Amend: If you believe that there is a mistake in your PHI, or that a piece of information is missing, 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. Upon your request, I will discuss with you the details of the amendment process. You must provide the request and your reason for the request in writing.
• Right to Receive a List of the Disclosures I have made: You generally have the right to receive an accounting of disclosures of PHI. Upon your request, I will discuss with you the details of the accounting process. I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). A request for accounting of disclosures must be in writing. The first accounting within a 12-month period will be free. For additional accountings, I may charge for its costs after notifying you of the cost involved and giving you the opportunity to withdraw or modify your request before any costs are incurred.
• 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.

VIII. 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, please feel free to discuss your concerns with me at any time. If you believe that your privacy rights have been violated and wish to file a complaint with me, please file it in writing. When filing a complaint, include your name, address, and telephone number, and I will respond. You may also send a written complaint to 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.

IX. Effective Date, Restrictions, and Changes to Privacy Policy

This notice is effective February 8th, 2021. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice in writing.