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. Uses and Disclosures
for Treatment, Payment, and Health Care Operations
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
your health care. An example of treatment would be when we consult with another
health care provider, such as your family physician or another psychologist. – 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 our
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 practice such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you. ·
“Disclosure” applies to activities
outside of our practice, such as releasing, transferring, or providing access
to information about you to other parties. Uses
and Disclosures Requiring Authorization
We 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 we are asked for
information for purposes outside of treatment, payment and 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 our 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, and the law provides the insurer the right to
contest the claim under the policy. Uses and Disclosures
with Neither Consent nor Authorization
We may use or disclose PHI without your
consent or authorization in the following circumstances: §
Child
Abuse: If we have a reason to suspect that a child
has been abused or neglected, we are required by law to report this to the
Bureau of Child and Family Services. §
Adult
and Domestic Abuse: If we suspect or have a good faith
reason to believe that any incapacitated adult has been subject to abuse,
neglect, self neglect or exploitation, or is living in hazardous conditions, we
are required by law to report that information to the Commissioner of the
Department of Health and Human Services.
§
Health
Oversight: If the New Hampshire Board of Psychological
Examiners is conducting an investigation, then we are required to disclose your
mental health records upon receipt of a subpoena from the Board. §
Judicial
or Administrative Proceedings: If you are involved
in a court proceeding and a request is made for information about the
professional services that we provided you and/or the records thereof, such information
is privileged under state law, and we may not release information without your
written authorization, 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. §
Serious
Threat to Health or Safety: If you have
communicated to us a serious threat of physical violence against a clearly
identified or reasonably identifiable victim or victims, or if you have made a
serious threat of substantial damage to real property, we are required by law
to take reasonable precautions to provide protection from such threats by
warning the victim or victims of your threat and to notify the police
department closest to your residence or the potential victim’s residence. Furthermore, if you present a clear and
present danger to yourself and refuse to accept further appropriate treatment,
and I have a reasonable basis to believe that you need to be committed to a
hospital or need other treatment through the state mental health system, I must
seek said commitment/treatment and may contact members of your family or other
individuals if it would assist in protecting you. 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, 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 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 us. Upon 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 our mental health and billing records used to
make decisions about you for as long as the PHI is maintained in the record. On
your request, we will discuss with you the details of the request 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. 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 for which you have neither provided
consent nor authorization (as described above in this Notice). 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 this notice from us upon request, even if you have agreed to receive
the notice electronically. Psychologist’s Duties: §
We are required by law to maintain the
privacy of PHI and to provide you with a notice of our legal duties and privacy
practices with respect to PHI. §
We reserve the right to change this
Notice. We reserve the right to make the revised or changed Notice effective
for medical information we already have about you as well as any information we
receive in the future. We will post a copy of the current Notice in our office
with the effective date in the upper right corner of the first page. Questions and
Complaints
If you have questions about this notice,
disagree with a decision we make about access to your records, or have other
concerns about your privacy rights, you may contact our Privacy Officer,
Jennifer Randolph, by telephone at (603) 653-0330 or by mail at 20 West Park
Street, Suite 207, Lebanon, NH, 03766. If you believe that your privacy rights have
been violated and wish to file a complaint with us/our office, you may send
your written complaint to our Privacy Officer, Jennifer Randolph, at 20 West
Park Street, Suite 207, Lebanon, NH, 03766.
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. We will not retaliate against you
for exercising your right to file a complaint. Effective Date
This notice will go into effect on August 1,
2004. |
