NOTICE OF PRIVACY PRACTICES

 

This notice describes how medical information about you may be used, disclosed and safeguarded, and how you can get access to this information. Please review it carefully.

 

I.               My Responsibility

 

The confidentiality of your personal health information is very important to me. Your health information includes records that I create and obtain when I provide your care, such as a record of your symptoms, examination and test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information that I maintain related to your care.

 

This Notice describes how I handle your health information and your rights regarding this information. Generally speaking, I am required to:

 

-        Maintain the privacy of your health information as required by law;

 

-        Provide you with this Notice of my duties and privacy practices regarding the health information about you that I collect and maintain;

 

-        Follow the terms of my Notice currently in effect.

 

II.              Uses and Disclosures of Information

 

Under federal law, I am permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. Whenever possible, I will obtain your consent before disclosing any such information. Below are some examples to clarify these terms:

Treatment: I consult with your therapist or family doctor about your condition.

 

Payment: Your health information is disclosed to your insurer to obtain reimbursement. In these situations, I will only disclose only the minimum amount of information necessary. As I am not a participating-provider in any insurance plans, you will be responsible for providing me with the appropriate forms and, therefore, aware of the information they are requesting.

 

Health Care Operations: This refers to administrative activities such as services or audits that relate to the operation of my practice.

 

 

III.            Other Uses and Disclosures

 

In addition to uses and disclosures related to treatment, payment, and health care operations, I may also use and disclose your personal information without authorization for the following additional purposes:

 

Serious Threat to Health or Safety:

I may disclose your health information to protect you or others from a serious threat of harm by you.

 

Abuse, Neglect, or Domestic Violence:

As required or permitted by law, I may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, I will use my professional judgment in deciding whether or not to make such a report. If feasible, I will inform you promptly that I have made such a disclosure.

 

Business Associates:

I may share health information about you with business associates who are performing services on my behalf. For example, I may contract with a company to service and maintain my computer systems, or to do my billing. My business associates are obligated to safeguard your health information. I will share with my business associates only the minimum amount of personal health information necessary for them to assist me.

 

Communications with Family and Friends:

I may disclose information about you to persons who are involved in your care or payment for your care, such as family members, relatives, or close personal friends. Any such disclosure will be limited to information directly related to the person’s involvement in your care.

 

If you are available, I will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, I will use my professional judgment to determine what is in your best interest regarding any such disclosure.

 

Coroners, Medical Examiners, and Funeral Directors:

I may disclose health information about you to a coroner or medical examiner, for example, to assist in the identification of a decedent or determining cause of death. I may also disclose health information to funeral directors to enable them to carry out their duties.

 

Food and Drug Administration (FDA):

I may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device.

 

Health Care Oversight:

I may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency to facilitate auditing, inspection, or investigation related to my provision of health care, or to the health care system.

 

Judicial or Administrative Proceedings:

In case where you are involved in a court proceeding and a request is made for you personal health information, this information is privileged under state law and I will not release it without your consent or a court order.

 

Law Enforcement:

I will disclose health information about you to a law enforcement official only if obligated by law.

 

Notification:

I may notify a family member, your personal representative, or other person responsible for your care, of your location, general condition, or death.

 

If you are available, I will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, I will use my professional judgment to determine what is in your best interest regarding any such disclosure.

 

Personal Representative:

If you are an adult or emancipated minor, I may disclose health information about you to a personal representative authorized to act on your behalf in making decisions about your health care.

 

Public Health Activities:

As required or permitted by law, I may disclose health information about you to a public health authority, for example, to report disease, injury, or vital events such as death.

 

Required By Law:

I may disclose health information about you as required by federal, state, or other applicable law.

 

Any Other Use or Disclosure -- Authorization Required:

Before using or disclosing your personal health information for any other purpose not identified above, I will obtain your written authorization. Unless action has already been taken in reliance on the authorization, you have a right to revoke such authorization by submitting your request in writing to me.

 

IV.            Psychotherapy Notes

 

In the course of your care with me, I may keep separate notes during the course of your therapy sessions about our conversations. These notes, known as “psychotherapy notes”, are kept apart from the rest of your medical record and their confidentiality is subject to greater protection. They do not include basic medical information about your diagnosis or treatment.

 

Psychotherapy notes may be disclosed by a therapist only after you have given written authorization to do so. (Limited exceptions exist, e.g. in order for me to prevent harm to yourself or others, and to report child abuse/neglect). You cannot be required to authorize the release of your psychotherapy notes in order to obtain health-insurance benefits for your treatment, or enroll in a health plan. Psychotherapy notes are also not among the records that you may request to review or copy. If you have any questions, feel free to discuss this subject with me.

 

V.             Your Health Information Rights

 

Under the law, you have certain rights regarding the health information that I collect and maintain about you. This includes the right to:

 

-        Request that I restrict certain uses and disclosures of your health information; I am not, however, required to agree to a requested restriction.

 

-        Request that I communicate with you by alternative means, such as making records available for pick-up, or mailing them to you at an alternative address, such as a P.O. Box. I will accommodate reasonable requests for such confidential communications.

 

-        Request to review, or to receive a copy of, a summary of the health information about you that is maintained in my files. If I am unable to satisfy your request, I will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.

 

-        Request that I amend the health information about you that is maintained in my files. Your request must explain why you believe my records about you are incorrect, or otherwise require amendment. If I am unable to satisfy your request, I will tell you in writing the reason for the denial and tell you how you may contest the decision, including your right to submit a statement (of reasonable length) disagreeing with the decision. This statement will be added to your records.

 

-        Request a list of my disclosures of your health information. This list, known as an “accounting” of disclosures, will not include certain disclosures, such as those made for treatment, payment, or health care operations. I will provide you the accounting free of charge, however if you request more than one accounting in any 12 month period, I may impose a reasonable, cost-based fee for any subsequent request. Your request should indicate the period of time in which you are interested (for example, “from May 1, 2003 to June 1, 2003”). I will be unable to provide you an accounting for any disclosures for a period of longer than six years.

-        Request a paper copy of this Notice.

 

In order to exercise any of your rights described above, you must submit your request in writing. If you have questions about your rights, please speak with me in person or by phone during normal office hours.

 

VI.            To Request Information or File a Complaint

 

If you believe your privacy rights have been violated, you may file a written complaint by mailing it to me or delivering it in person. You may complain to the Secretary of Health and Human Services (HHS) by writing to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201; by calling 1-(800) 368-1019; or by sending an email to OCRprivacy@hhs.gov. I cannot, and will not, make you waive your right to file a complaint as a condition of receiving care from us, or penalize you for filing a complaint.

 

VII.          Revisions to this Notice

 

I reserve the right to amend the terms of this Notice. If this Notice is revised, the amended terms shall apply to all health information that I maintain, including information about you collected or obtained before the effective date of the revised Notice. If the revisions reflect a material change to the use and disclosure of your information, your rights regarding such information, my legal duties, or other privacy practices described in the Notice, I will promptly distribute the revised Notice.

 

VIII.         Effective Date: December 1, 2005