HIPAA and CONFIDENTIALITY INFORMATION
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION
ABOUT YOU MAYBE 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
Effective/Last Revised Date: June 15, 2008
Consultation and Counseling is required by federal law to protect
the privacy of your health information in the context of your
mental health and substance abuse health care administered by
this agency. We are also required to send you this notice. which
explains how we may use information about you and when we can
give out or "disclose" that information to others. You also have
rights regarding your health information that are described in
this notice.
The terms "information" or "Health information" in this notice
include any personal information that is created or received by a
health care provider that relates to your physical or mental
health or condition, the provision of health care to you, or the
payment for such health care.
We have the right to change our privacy practices. If we do, we
will provide the revised notice to you within 60 days by direct
mail or post it in our agency office or on the website.
We may use or disclose your protected health information (PHI),
for treatment, payment, and health care operations purposes with
your consent. 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"
-Treatment is when we provide, coordinate or manage your health
care and other services related to yow health care. An example of
treatment would be when we consult with another health care
provider, such as your family physician or another Therapist.
Another example would be when we release your treatment plan to
your insurance company and/or to your primary care physician.
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.
Health Care Operations are activities that relate to the
performance and operation of my practice. Examples of health care
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. clinic,
practice group. etc.] such as sharing, employing, applying,
utilizing, examining, and analyzing infol111ation that identifies
you.
"Disclosure" applies to activities outside of our [office,
clinic, practice group, etc.], such as releasing, transferring,
or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
HOW WE USE OR DISCLOSE INFORMATION
We must use and disclose your health information to provide
information:
To you or someone who has the legal right to act for you (your
personal representative);
To the Secretary of the U.S. Department of Health and Human
Services, if necessary, to ensure that your privacy is protected;
and - Where required by law.
We may use or disclose PHI for purposes outside of treatment,
payment, or health care operations when your appropriate
authorization is obtained. An "authorization" is written
permission above and beyond the general consent that permits only
specific disclosures. In those instances when we asked for
information for purposes outside of treatment, payment or health
care 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 your
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 light to contest the claim under the
policy.
III. Uses and Disclosures with Neither Consent nor
Authorization
We have the right to use and disclose health information
to pay for your health care and operate our business. For
example, we may use your health information:
To process claims for health care services you receive.
For Treatment. We may disclose health information to your
doctors or hospitals to help them provide medical care to you.
For Health Care Operations. We may use or disclose health
information as necessary to operate and manage our business and
to help manage your health care coverage. For example, we might
talk to your doctor to suggest a disease management or wellness
program that could help improve your general health. To
Provide Information on Health Related Programs or Products
such as alternative medical treatments and programs or about
health related products and services.
To Referral Sources. If you are referred through another
agency such as your Primary Care Physician, Juvenile Court, DFCS,
Psychiatric Hospital, CMHC, etc., we may share summary
information and admission and discharge information with the
referral source. In addition, we may share other health
information with the referral source for case management purposes
if the referral source agrees to special restriction on its use
and disclosure of the information.
For Appointment Reminders. We may use health information
to contact you for appointment reminders with providers who
provide medical or mental health care to you.
We may use or disclose PHI without your consent or
authorization in the following circumstances under limited
circumstances:
To Persons Involved With Your Care. We may use or disclose
your health information to a person involved in your care, such
as a family member, when you are incapacitated or in an
emergency, or when permitted by law.
For Public Health Activities such as reporting disease
outbreaks.
For Reporting Victims of Abuse, Neglect or Domestic
Violence to government authorities. including social service
or protective service agencies. lf we have reasonable cause to
believe that a child has been abused, we must report that belief
to the appropriate authority. If we have reasonable cause to
believe that a disabled adult or elder person has had a physical
injury or injuries inflicted upon such disabled adult or elder
person, other than by accidental means, or has been neglected or
exploited, we must report that belief to the appropriate
authority.
For Health Oversight Activities such as governmental
audits and fraud and abuse investigations. If we are the subject
of an inquiry by the Georgia Composite Board. we may be required
to disclose protected health information regarding you in
proceedings before the Board.
For Judicial or Administrative Proceedings such as in
response to a court order, search warrant or subpoena. If you are
involved in a court proceeding and a request is made about the
professional services we provided you or the records thereof,
such information is privileged under state law, and we will not
release information without your written consent, subpoena 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.
For Law Enforcement Purposes such as providing limited
information to locate a missing person.
Serious Threat to Health or Safety. If we determine, or
pursuant to the standards of my profession should determine, that
you present a serious danger of violence to yourself or another,
we may disclose information in order to provide protection
against such danger for you or the intended victim_
For Specialized Government Functions such as military and
veteran activities, national security and intelligence
activities, and the protective services for the President and
others.
For Workers Compensation including disclosures required by
state workers compensation laws relating to job-related injuries.
We may disclose protected health information regarding you as
authorized by and to the extent necessary to comply with 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.
For Research Purposes such as research related to the
prevention of disease or disability, if the research study meets
all privacy law requirements. To Provide Information regarding
Decedents. We may disclose information to a coroner or
medical examiner to identify a deceased person, determine a cause
of death, or as authorized by law. We may also disclose
information. to funeral directors as necessary to carry out their
duties.
For Organ Procurement Purposes. We may use or disclose
information for procurement, banking or transplantation of
organs, eyes or tissue.
If a use or disclosure of health information. is prohibited or
materially limited by other applicable law, it is our intent to
meet the requirements of the more stringent law.
If none of the above reasons applies, then we will obtain your
written authorization to use or disclose your health
information . If a use or disclosure of health information is
prohibited or materially limited by other applicable law, it is
our intent to meet the requirements of the more stringent law. In
some states, your authorization may also be required for
disclosure of your health information. In many states, your
authorization may be required in order for us to disclose your
highly confidential health information, as described below. Once
you have given us authorization to release your health
information, we cannot guarantee that the person to whom the
information is provided will not disclose the information. You
may take back or "revoke" your written authorization, except if
we have already acted based upon your authorization. To revoke an
authorization, contact the phone owner listed below on this
notice.
HIGHLY CONFIDENTIAL INFORMATION
Federal and applicable state laws may require special privacy
protections for highly confidential information about you.
"Highly confidential information" may include confidential
information under Federal law governing alcohol and drug abuse
information as well as state laws that often protect the
following types of information:
HIV/AIDS;
Mental health;
Genetic tests;
Alcohol and drug abuse;
Sexually transmitted diseases and reproductive health
information; and Child or adult abuse or neglect, including
sexual assault.
IV. Patient's Rights and Therapist's Duties
Patient's Rights
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 light 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 seeing
therapists. On your request, we will send your bills to another
address.)
Right to Inspect and Copy - You have the right to inspect
or obtain a copy (or both) of PHI in your mental health and
billing records used to make decisions about you for as long as
the PHI is maintained in the record. We may deny yow' 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. Your therapist may
also deny access to your Psychotherapy Notes.
Right to Amend - You have the right to request an
amendment of PHI for as long as the PHI is maintained in the
record. 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, even if you have
agreed to receive the notice electronically.
Therapist's Duties
We are required by law to maintain the privacy of PHI and to
provide you with a notice of my 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.
If we revise these policies and procedures, we will notify
you by mail or on your next session. You may obtain a copy of
this notice at the local office or website.
V. Complaints
Contacting. If you have any questions about this notice or
want to exercise any of your rights, please call 845-473-4939.
Please specify that your question or concern is in reference to
your mental health and/or substance abuse protected health
information.
Filing a Complaint. If you believe your privacy rights
have been violated, you may file a complaint with us at the
following address:
Compliance Department - Privacy Complaints
You may also notify the Secretary of the U.S. Department of
Health and Human Services of your complaint. We will not take any
adverse action against you for filing a complaint.
VI. Cancellation Policy
In the Event of an emergency, you will not be charged for session
cancellation. Cancellations for any other reasons that are not
received by clinic staff at least 24 hours prior to the scheduled
session win be billed at the session rate.
VIII. Effective Date, Restrictions, and Changes to Privacy
Policy
This notice will go into effect on October 1, 2006. We reserve
the right to change the terms of this notice and to make the new
notice provisions effective for all PHI that we maintain.
IX. Patient's Consent
I consent for my therapist to communicate with me via phone call,
text message, and email. I am aware that these methods of
communication may not always be secure. I consent for my
therapist to use my identifying information for payment purposes
via Square.