THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, the NASW Code of Ethics and The American Psychological Association Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.
For Payment. I may use and disclose PHI so that I can provide the necessary information for your insurance carrier, explaining the treatment services you received. This will only be done with your authorization. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
For Communication with you. When I need to contact you by telephone I will use the phone numbers you have given me on the signature form to do this.
Required by Law. Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Without Authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
Verbal Permission. I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your treatment will not be affected if you choose to not sign an
authorization.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your
request in writing to me.
COMPLAINTS
If you believe I have violated your privacy rights, you have the right to file a complaint in writing to me or with the Secretary of Health and Human Services. I will not retaliate against you for filing a complaint.
The effective date of this Notice is December 1, 2015.
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