NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
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.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
We may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations purposes with your written authorization. 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” o 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 healthcare provider, such as your family physician or another therapist. o 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. o HealthcareOperationsareactivitiesthatrelatetotheperformanceandoperationofourpractice.Examples of healthcare 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 group practice such as releasing, transferring, or providing access to information about you to other parties.
• “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
II. Other Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or healthcare operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment or healthcare operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we 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 or Psychotherapy Notes) 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, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures without Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances: This includes narrowly-defined disclosures of law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA- regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
• Child Abuse - If we have reason to believe that a child has been subjected to abuse or neglect, we must report this belief to the appropriate authorities.
• Adult and Domestic Abuse - If we have reason to believe that an adult is in need of protective services because of abuse or neglect by another person, we must report this belief to the appropriate authorities.
• Health Oversight Activities - If we receive a subpoena from a board of psychology or social work in Maryland, DC or Virginia, we must disclose the relevant PHI pursuant to that subpoena or lawful request.
• Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and we will not release information without your written authorization 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 communicate to us a specific threat of imminent harm against another individual or if we believe that there is clear, imminent risk of physical or other mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.
IV. Patient’s Rights and Therapist’s Duties
You have the following rights regarding the PHI that this office maintains about you.
• 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 being seen at our office. On your request, we will send your bills to another address.) You will be provided with a form on which to list your authorized means of communications. It will be understood that there may be times when you may provide your therapist with additional ways in which to communicate, outside of those listed on the form you have signed. It will be understood that these also will be considered patient authorized confidential communications. (For example, you are out of town and wish to speak to your therapist. In such a case, you may leave a voicemail providing your therapist with a contact number, other than those listed on your authorization form, by which to communicate with you at the location where you are.)
• 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 your for as long as the PHI is maintained in the record. To inspect and/or obtain a copy of your PHI, you must complete our request form and submit it to the Privacy Officer. If you request copies, we will charge you $0.10 per page. 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. In addition, you must provide a reason that supports your request. 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.
• Right to be Notified if There is a Breach of Your Unsecured PHI – You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised. Therapist’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.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact me at 301.750.7334.
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. We will not retaliate against you or penalize you in any way for exercising your right to file a complaint.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on July 30, 2019.
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 notify you of changes made to the privacy policy.
Acknowledgment of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.