Notice of Psychologists’ 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 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:
– Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.
– Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I 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.
I may use or disclose PHI for purposes outside of treatment, payment, and 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 I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I 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) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
I may use or disclose PHI without your consent or authorization in the following circumstances:
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, you may contact _________________ [add name, or title, and telephone number of a person in your office to contact for further information (which can be you)].
If you believe that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written complaint [or specify other method for patients to file complaint with you] to ______[same person as above, include mailing address, e-mail address or other contact information appropriate for suggested method of contact].
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. I will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on _______________[add date, which may not be earlier than the date on which the notice is printed or otherwise published.]
[If you (the psychologist) elect to limit the uses or disclosures that you are permitted to make under this subpart, add the following:]
I will limit the uses or disclosures that I will make as follows:______________________
[Note – You (the psychologist) may include in your notice a limitation(a restriction) affecting your right to make a use or disclosure. This restriction, however, may not include a limitation affecting the psychologist’s right to make a use or disclosure that is required by law or, when in good faith, to use or disclose to avert a serious threat to health or safety of a person or the public and such use or disclosure is made to a person or persons reasonably able to prevent or lessen the threat (including the target of the threat)].
[If you (the psychologist) want to apply a change in your more limited uses and disclosures to PHI created or received prior to issuing a revised notice, the revised notice must include a statement that you reserve the right to change the terms of the notice and to make the new notice provisions effective for all protected health information that you maintain. The statement must also describe how you will provide individuals with a revised notice. (See example below.)]
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 by ____________________ [Describe how you will provide individuals with a revised notice.]