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.

  1. Uses and Disclosures for Treatment, Payment, and Health Care Operations

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:

  • PHI”(Protected Health Information) refers to information in your health record that could identify you.
  • “Treatment, Payment and Health Care Operations”

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 with your knowledge and consent unless it would be detrimental to your mental, physical, or psychological health or to the health of others concerned.

- 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.

  • Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

 Uses and Disclosures Requiring Authorization

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 as regards your personal, mental, psychological or physical health status. 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.

 III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If, in my professional capacity as dictated by State and Federal disclosure laws, a child comes before me which I have reasonable cause to suspect is an abused or maltreated child, or I have reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or other person legally responsible for such child comes before me in my professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, I must report such abuse or maltreatment to the statewide central register of child abuse and maltreatment, or the local child protective services agency. I am immune from personal prosecution for issuing or releasing this information by State and or Federal Statutes.

􀂃 Health Oversight: If there is an inquiry or complaint about my professional conduct

to the Florida State Board for Psychology, I must furnish to the Florida Department of Medical Quality Assurance, your confidential mental health records relevant to this inquiry according to State and Federal Statutes.

 Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.

  • Serious Threat to Health or Safety: I may disclose your confidential information to protect you or others from a serious threat of harm by you to yourself, me, or others.

􀂃 Worker’s Compensation: If you file a worker’s compensation claim, and I am treating you for the issues involved with that complaint, then I must furnish to the chairman of the Worker’s Compensation Board records which contain information regarding your psychological condition and treatment according to Florida State and Federal Statutes.

 Patient's Rights and Psychologist'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 about you. However, I am 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 seeing me. Upon your written request, I will send your bills to another address or another responsible person. The address must be correct and current and the responsible party must be aware of and accepting of this arrangement.)
  • Right to Inspect and Copy – You have the right to inspect the PHI in my mental health and billing records. According to State and Federal Statutes, I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed by the proper legal authorities. On your request, I 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. I may deny your request. On your request, I 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I 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 me upon request, even if you have agreed to receive the notice electronically. I am not responsible for any electronic transmissions which may fall into the hands of unauthorized personnel. I will take all precautions to insure that material transmitted in the fashion will be protected to the utmost of my capabilities.

Psychologist’s Duties:

  • I am 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.
  • I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
  • If I revise my policies and procedures, I will mail the revised Notice to you, as well as making it available in my office.

 Questions and Complaints

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 Leslie Sadoff (or other official assigned to this office), the Assistant Director, or Robert H. Reiner, the Executive Director, at (212) 860-8500.

If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to the address above.

 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. If I am found innocent of the allegations against me made by you or your dually authorized representatives, you will be held responsible for any and all charges, fees, attorney’s fees, court costs, and my professional time while participating in these proceedings.

 Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on ______________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 either distributing it to you in the office or mailing it to your home address.

  _____________________________________________________________

Print name

  ____________________________________________________________

Patient Signature

  _____________________________________________________________

Name & Signature of Guardian or patient advocate (if applicable)