Integrative Mindworks with April Rubino, M.Ed. Idaho LCPC-6014
firstname.lastname@example.org (208) 882-8159
814 S. Washington Street, Moscow, Idaho 83843
Notice of Policies and Practices to Protect the Privacy of Your Health Information (HIPAA)
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
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” 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 counselor.
– 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.
II. Uses and Disclosures Requiring Authorization
I 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 in which I am asked for information for purposes outside of treatment, payment or 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, that 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, 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 I have reason to believe that a child under the age of eighteen (18) years has been abused, abandoned or neglected or have information from someone who observes the child being subjected to conditions or circumstances that would reasonably result in abuse, abandonment or neglect, I must report this belief or observation to the appropriate authorities.
- Health Oversight Activities – If the Idaho Board of Psychological Examiners is investigating me and/or my practice, I may be required to disclose protected health information regarding you.
- Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or when the evaluation is court-ordered. I will inform you in advance if this is the case.
- Serious Threat to Health or Safety – If you communicate to me an explicit threat of imminent serious physical harm or death to identifiable victim(s), and I believe you may act on the threat, I have a duty to take the appropriate measures to prevent harm to that person or persons, including disclosing information to the police and warning the intended victim. If I have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, I may need to disclose information in order to protect you. In both cases, I will only disclose what I feel is the minimum amount of information necessary.
- Worker’s Compensation – I 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.
IV. Patient’s Rights and Counselor’s Duties
- Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information; 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. On your request, I 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 my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. 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. Upon 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. Upon 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 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 during our work together, I will provide you with a paper copy of the revisions.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W.. Washington, D.C. 20201.
This is effective as of July 23, 2010.
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 copy of the revised notice during session or by mail.