Healthcare Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices
(This form fulfills and/or exceeds the current HIPAA requirements)
I.
THIS NOTICE DESCRIBES HOW MEDICAL/CLINICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
II.
IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am
required to insure that your PHI is kept private. The PHI constitutes
information created or noted by me that can be used to identify you. It
contains data about your past, present, or future health or condition, the
provision of health care services to you, or the payment for such health care.
I am required to provide you with this Notice about my privacy procedures. This
Notice must explain when, why, and how I would use and/or disclose your PHI.
Use of PHI means when I share, apply, utilize, examine, or analyze information
within my practice; PHI is disclosed when I release, transfer, give, or
otherwise reveal it to a third party outside my practice. With some exceptions,
I may not use or disclose more of your PHI than is necessary to accomplish the
purpose for which the use or disclosure is made; however, I am always legally
required to follow the privacy practices described in this Notice.
Please note
that I reserve the right to change the terms of this Notice and my privacy
policies at any time. These changes will be made based on the legal and ethical
standards of my profession and as required law. In addition, I may be required
to change this Notice as future adjustments to HIPAA is so ordered by the
Federal Government. Any changes will apply to PHI already on file with me.
Before I make any important changes to my policies, I will immediately change
this Notice and post a new copy of it in my office and on my website. You may
also request a copy of this Notice from me, or you can view a copy of it in my
office. While the new HIPAA standard are intended to provide minimal and
consistent standards across all health care profession, as a Psychologist I
must adhere to a higher ethical standard. Consequently, no information about
you will be disclosed without your knowledge and/or consent, unless they are
classified as exceptions to confidentiality. Those exceptions are listed below.
III.
HOW I WILL USE AND DISCLOSE YOUR PHI.
As stated in
your confidentiality agreement with me, I will disclose information in your PHI
for many different reasons. Some of the uses or disclosures will require your
prior written authorization; others, however, will not. Below you will find the
exceptions to confidentiality and uses that would require partial or complete
disclosure of your PHI.
1. To obtain payment for treatment. I may use and disclose
your PHI to bill and collect payment for the treatment and services I provided
you. Example: I might send your PHI to your insurance company or health plan in
order to get payment for the health care services that I have provided to you.
I could also provide your PHI to business associates, such as billing
companies, claims processing companies, and others that process health care
claims for my office. Note that this information is limited to only that which
is required for collections.
2. Medical Emergencies. Your consent is not required if you
need emergency treatment provided that I attempt to get your consent after
treatment is rendered. In the event that I try to get your consent but you are
unable to communicate with me (for example, if you pass out in my office and
are unconscious) but I think that you would consent to such treatment if you
could, I may disclose your PHI, providing limited information i.e. demographics
and medical information to secure appropriate medical care.
3. If disclosure is compelled by a judge.
4. If disclosure is compelled by the patient or the patient’s
representative pursuant to California Health and Safety Codes or to
corresponding federal statutes of regulations, such as the Privacy Rule that
requires this Notice.
5. To avoid harm. I may provide PHI to law enforcement
personnel or persons able to prevent or mitigate a serious threat to the health
or safety of a person or the public. Specifically, if you tell me you intent to
commit a crime, I must report it to the police.
6. Dangerousness to self or others. If disclosure is
compelled or permitted by the fact that you are in such mental or emotional
condition as to be dangerous to yourself or the person or property of others,
and if I determine that disclosure is necessary to prevent the threatened
danger.
7. If disclosure is mandated by the
8. If disclosure is mandated by the
9. If disclosure is compelled or permitted by the fact that you
tell me of a serious/imminent threat of physical violence by you against a
reasonably identifiable victim or victims. I am also required to warn the
persons or persons to whom the threat is made or any other person(s) who could
be injured as a part of that threat.
10. For public health activities. Example: In the event of
your death, if a disclosure is permitted or compelled, I may need to give the
county coroner information about you.
11. Legal proceedings. If an arbitrator or arbitration panel compels
disclosure, when arbitration is lawfully requested by either party, pursuant to
subpoena duces tectum (e.g., a subpoena for mental health records) or
any other provision authorizing disclosure in a proceeding before an arbitrator
or arbitration panel.
12. For Consultation. I may at times speak with
professional colleagues about our work without asking permission, but your
identity will be disguised.
13. Administrative purpose. An administrative assistant
employed by me may have access to locked records but is legally charged with
confidentiality.
14. Minors. Clients under 18 do not have full
confidentiality from their parents. Parents may request their child(ren)’s PHI.
However, the request may compromise trust and safety and undermine the
therapeutic process. Consequently, parents are asked to respect the
confidentiality of their child(ren)’s treatment, knowing that they will be
informed if the minor shares information that requires me to legally and/or
ethically break confidentiality and/or shares information indicating that the
minor is physically at risk/danger.
15. I am permitted to contact you, without your prior
authorization, to provide appointment reminders or information about
alternative or other heath-related benefits and services that may be of
interest to you.
16. If disclosure is otherwise specifically required by law and is
not in conflict with my ethical requirements. At all times, I will strive to
comply with the highest ethical and legal standard to insure your privacy,
confidentiality, and clinical care.
IV.
OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION.
In any other
situation not described in Section III above, I will request your written
authorization before using or disclosing any of your PHI. Even if you have
signed an authorization to disclose your PHI, you may later revoke that authorization,
in writing, to stop any future uses and disclosures (assuming that I haven't
taken any action subsequent to the original authorization) of your PHI by me.
V.
WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are
your rights with respect to your PHI:
A. The
Right to See and Get Partial Copies of Your PHI. In general, you have the
right to see your PHI that is in my possession; however, you must request it in
writing. You will receive a response from me within 30 days of my receiving
your
written request.
Under certain circumstances, I may feel I must deny your request, but if I do,
I will give you, in writing, the reasons for the denial. I will also explain
your right to have my denial reviewed. You may ask for copies of your PHI, I
will charge you not more than $.25 per page for information that you have
provided such as demographics and history as contained in your Client
Questionnaire. Clinical information will not be released to you directly.
Clinical information may be sent to another professional i.e. therapist,
attorney with your consent: I may see fit to provide them with a summary or
explanation of the PHI, but only if you agree to it, as well as to the cost, in
advance.
B. The
Right to Choose How I Send Your PHI to You. It is your right to ask that
your PHI be sent to you at an alternate address (for example, sending
information to your work address rather than your home address) or by an
alternate method (for example, via email instead of by regular mail). I am
obliged to agree to your request providing that I can give you the PHI, in the
format you requested, without undue inconvenience and which does not violate
your privacy and/or confidentiality.
C. The
Right to Get a List of the Disclosures I Have Made. You are entitled to a
list of disclosures of your PHI that I have made. However, the list will not
include uses or disclosures to which you have already consented or disclosures
made before April 15, 2003. After April 15, 2003, HIPAA requires that
disclosure records will be held for six years. However, in compliance with the
standards of my profession, all records will be held for a minimum of seven
years unless otherwise indicated. Note records may be maintained longer if it
is clinically warranted and in the best interest of the individual to do so. I
will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I give you will include disclosures made in
the previous six years (the first six year period being 2003-2009) unless you
indicate a shorter period. The list will include the date of the disclosure, to
whom PHI was disclosed (including their address, if known), a description of
the information disclosed, and the reason for the disclosure. I will provide
the list to you at no cost, unless you make more than one request in the same
year, in which case I will charge you a reasonable sum based on a set fee for
each additional request.
D. The
Right to Amend Your PHI. If you believe that there is some error in your
PHI or that important information has been omitted, it is your right to request
that I correct the existing information or add the missing information. Your
request and the reason for the request must be made in writing. You will
receive a response within 60 days of my receipt of your request. I may deny
your request, in writing, if I find that: the PHI is (a) correct and complete,
(b) forbidden to be disclosed, (c) not part of my records, or (d) written by
someone other than me. My denial must be in writing and must state the reasons
for the denial. It must also explain your right to file a written statement
objecting to the denial. If you do not file a written objection, you still have
the right to ask that your request and my denial be attached to any future
disclosures of your PHI. If I approve your request, I will make the change(s)
to your PHI. Additionally, I will tell you that the changes have been made, and
I will advise
all others
who need to know about the change(s) to your PHI.
F. The
Right to Get This Notice by Email. You have the right to get this notice by
email. You have the right to request a paper copy of it, as well.
VI.
HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If, in your
opinion, I may have violated your privacy rights, or if you object to a
decision I made about access to your PHI, you are entitled to file a complaint
with me as listed in Section VII below. You may also send a written complaint
to the Secretary of the Department of Health and Human Services at
VII.
PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY
PRIVACY
PRACTICES
If you have
any questions about this notice or any complaints about my privacy practices,
or would like to know how to file a complaint with the Secretary of the
Department of Health and Human Services, please contact me at: