Policies and Practices to Protect the Privacy of Your Health Information

·         “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 psychologist.

-Payment is when I obtain reimbursement for your health care.  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 groups, etc] such as releasing, transferring, or providing access to information about you to other parties. 

·         “Authorization” is your written permission to disclose confidential mental health information.  All authorizations to disclose must be on a specific legally required form. 

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.  In those instances when 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 conversations 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 that 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. 

·         Child Abuse—If I believe that a child is a victim of child abuse or neglect, I must report this belief to the appropriate authorities. 

·         Adult and Domestic Abuse—If I believe or have reason to believe that an individual is an endangered adult, I must report this belief to the appropriate authorities. 

·         Health Oversight Activities—If the Indiana Attorney General’s Office (who oversees complaints brought against psychologists instead of the Indiana State Psychology Board) is conducting an investigation into my practice, then I am required to disclose PHI upon receipt of a subpoena. 

·         Judicial and Administrative Proceedings—If the patient is involved in a court proceeding and a request is made for information about the professional services I provided you and/or the record 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 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 communicate to me an actual threat of violence to cause serious injury or death against a reasonably identifiable victim or victims or if you evidence conduct or make statements indicating an imminent danger that you will use physical violence or use other means to cause serious personal injury or death to others, I may take the appropriate steps to prevent that harm from occurring.  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. 

·         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 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.  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.  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 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 provide you a copy of these revisions at the next appointment. 

If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to Indiana Professional Psychological Services, P. C. 6408 Constitution Drive, Fort Wayne, IN 46804.

You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services.  I 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. 

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