Notice of Therapists’ 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 am committed to providing you with high quality care and to forming a relationship with you that is built on trust. I understand that information about you is private and I am committed to protecting this information.

This notice describes how your health information may be used and disclosed by my office, your rights with regards to your health information and psychotherapy notes, and my duty to protect such information. It applies to all records of your care that I maintain, stored in writing, on a computer, or other means, I will keep this information in a safe and secure way that protects your privacy and confidentiality.

Your health information may be used and disclosed by my office for the following purposes without your legal permission:

Treatment, Payment, and Business Purposes. I use and disclose your health information to enable my office to provide treatment to you, obtain payment for your care, and manage and administer my practice. For example, I may use and disclose your health information to your insurer, HMO, or other third party payer to obtain payment for the services that I provide you. Also, in consulting with a specialist regarding your health care treatment, I use and disclose your information.

Individuals Involved in Your Care or Payment or Notification. I may disclose your information to your family members or caregivers who are involved in your care or who assist you in paying for your care. This notification may also be for a disaster relief effort, such as the American Red Cross.

Appointment Reminders. Your health information may also be used and disclosed when my office contacts you to remind you of an upcoming appointment.

To You. I will provide you with your health information upon your request for copying inspections and accounting purposes as discussed further in this notice under “Individual Rights.”

Required by Law. I will discuss your information when I am required to do so by federal, state, or local law.

Health Oversight Activities. I may disclose your information for health oversight activities, such as the disclosure of information in the investigation of a provider’s conduct to a state licensing board official.

To Avert a Serious Threat to Health and/or Safety. I may use and disclose your information if it is necessary to avert a serious threat to health or safety of yourself or others; or to assist law enforcement authorities in identifying or apprehending an individual.

Abuse, Neglect, or Domestic Violence. I may report your health information to government authorities if I have a reasonable belief that a situation involves abuse, neglect or domestic violence.

Judicial and Administrative Proceedings. I may release your health information for judicial and administrative proceedings. Such proceedings would include responses to court orders or subpoenas.

Workers’ Compensation. I may release your health information for the purpose of processing and adjudicating Workers’ Compensation claims.

For Specialized Government Functions. I may disclose your information if you are a member of the military as required by military authorities, or to federal officials for national security reasons as authorized by law.

Law Enforcement Purposes. I may disclose your information for law enforcement purposes if requested by law enforcement officials.

Quality and Cost of Services. I may provide your information to a nonprofit organization established by law for the purpose of ensuring quality services at reasonable prices. Such a disclosure may be to assist that nonprofit organization in determining the relative quality of services provided by one physician as compared to their peers.

Limited Treatment, Payment and Business Purposes. I may use or disclose your psychotherapy notes if it is for the purpose of defending the provider or practice against a legal action or other proceeding brought by you.

All other uses and disclosures require authorization. You may revoke an authorization in writing to prevent future use and disclosure of your health information.

Individual Rights

Restriction on Release. You may request that we not use or disclose your health information (1) for your treatment, payment, or the administration of my practice, (2) in notifying family members and friends of your condition or location, and (3) to family and caregivers involved in your care. I will consider your request but I am not legally required to accept it. If I do accept your request, I will not use or disclose your health information except as agreed, unless it is required in emergency situations.

Confidential Communications. You may request in writing that I communicate with you at a different location, or in an alternative manner. I will try to accommodate your request provided that you specify the alternative contact and pay any additional costs related to such requests.

Access and Amendment. In most cases, you have the right to inspect or receive a copy of health information that I use to make decisions about you. Additionally, if you believe that information in your record is incorrect or if important information is missing, you have the right to request that this information be corrected or amended.

Accounting. You may request a limited list of instances where I have disclosed your health information. The list will not include disclosures: (1) for treatment, payment or related administrative/management purposes; (2) to you; (3) to family or caregivers involved in your care or payment for your care, or for notifying your family/caregiver in situations where you indicate that you agreed to the disclosure; (4) under certain circumstances for national security or intelligence purposes; and (5) to correctional institutions or law enforcement officials having lawful custody of an inmate or information about an inmate or individual, under certain conditions. Additionally, disclosures to health oversight agencies or law enforcement officials may be temporarily suspended if such disclosures delay the activities of the agency or official.

Notice. You may obtain a paper copy of this notice from me upon request, regardless of whether you have received this notice electronically.

My Responsibilities

I am required by law to maintain the privacy of your health information and to provide you with notice of my legal duties and privacy practices with respect to your health information. I must abide by the terms of the notice currently in effect. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all health information that I maintain; however, before I make a significant change in the privacy policies, I will change the notice and post the new notice for you. I will provide you with a revised notice upon request. You can also request a copy of the notice at any time by contacting my office.

Complaints

If you feel that your privacy rights have been violated, you may inform my office by written notice. If you have additional questions, please contact me.