PENNSYLVANIA NOTICE FORM

 

Notice of Provider’s 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.

 

We are required by federal law (Health Insurance Portability and Accountability Act, or HIPAA) to maintain the privacy of your Protective Health Information (“PHI”). PHI’s personal information about you, including demographic information that we collect from you, that may be used to identify you and relates to your past, present, or future physical or mental health or condition, including treatment and payment for the provision of healthcare.

 

This Notice explains our legal duties and privacy practices with regard to your PHI. We are required by law to provide you with a copy of this notice and to abide by the terms of this Notice. Accordingly, please sign the statement in the appropriate space, below, acknowledging that we have provided you with a copy of this Notice. If you have elected to receive a copy electronically, you still have the right to obtain a paper copy upon request.

 

Uses and Disclosures for Treatment, Payment, and Health Care Operations

​

We may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations purposes with or without your consent. To help clarify these terms, here are some definitions:

• “Treatment, Payment, and Health Care Operations” – Treatment is when we provide, coordinate or manage your healthcare and other services related to your healthcare. An example would be when we consult with another healthcare provider, such as your family physician. Payment is when we obtain reimbursement for your healthcare. Examples include when we disclose your PHI to your health insurer to obtain payment for your healthcare or to determine eligibility or coverage. Health Care Operations or activities that relate to the administrative and technical performance and operation of our practice. Examples 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.

​​

Use and Disclosures Requiring Authorization

​

We may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations when your appropriate authorization is obtained. An “authorization” his 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 healthcare operations, we will obtain an authorization from you before releasing this information. We will also need to obtain authorization before releasing her psychotherapy notes. “Psychotherapy notes” are notes we’ve 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 (please see Section VI for further explanation). We will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this notice.

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.

​

III. 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 or Neglect: If we reason to suspect, on the basis of our professional judgment, that a child is or has been abused or neglected, we are required to report our suspicions to the authority or government agency vested to conduct child-abuse and neglect investigations. We are required to make such reports even if we do not see the child in our professional capacity. We are mandated to report suspected child abuse if anyone aged 14 or older tells us that he or she committed child abuse and/or neglect, even if the victim is no longer in danger. We are also mandated to report suspected child abuse if anyone tells us that he or she knows of any child that is currently being abused and/or neglected.

• Adult and Domestic Abuse: If we have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), we may report such to the local agency which provides protective services.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release information without your written consent, or a court order. The privilege does not apply when you are being evaluated for 1/3 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 express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and we determine, in our professional judgment, that you are likely to carry out that threat, we must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.

• Worker’s Compensation: If you file a worker’s compensation claim, we will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis.

• Corner’s and Funeral Directors: We may disclose health information about you to a corner if that information is pertinent to the corner’s duties, such as identifying a decedent or determining the cause of death. We may also disclose health information to funeral directors to enable them to carry out their duties.

• Food and Drug Administration (FDA): We may disclose health information about you to the FDA or an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug you are taking or a medical device you are using.

• De-Identified PHI – We may disclose health information about you if all identifying information is removed so your identity cannot be ascertained from the information disclosed (ie., on a completely anonymous basis)

• When the use and disclosure without your consent or authorization are allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state Department of Health), to a corner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

​

Patient’s Rights and Provider’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 all PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are in treatment. Upon your request, we will send your bills to another address.

• Right to Inspect and Copy – You the right to inspect and 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 your record. We may deny access to your PHI in certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

• Right to Amend – You the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny a 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 in Section III of 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 the notice from us upon request, even if you have agreed to receive the notice electronically.

• Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

• Right to be Notified if There is a Breach of Your Unsecured PHI – You have right to be notified if: (1) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (2) that PHI has not been encrypted to government standards; and (3) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

 

 

Provider’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 the privacy policies and practices described in this notice. Unless we notify you of such changes, however, required to abide by the terms currently in effect.

• If we revise the policies and procedures, we will post the relation in our waiting rooms, and you may request a copy from our Privacy Officer.

​

Complaints

​

If you’re concerned that we have violated your privacy rights, or you disagree with the decision we made about access to records, you may contact the following person: Privacy Officer, Reading Being Psychological Services, PC, 80 Gravel Pike, Suite B, Red Hill, PA 18076; phone – 484.624.2415.

​

You may also send a written complaint to the Secretary of the US Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

​

Psychotherapy Notes

​

In the course of your care with us, you will receive treatment from a mental health professional who keeps separate notes documenting or analyzing the contents of conversations during a private counseling session or a group, joint, or family counseling session. These notes, known as “psychotherapy notes,” are kept apart from the rest of your medical record and typically do not include basic information such as your medication treatment record, counseling session start and stop times, the types and frequencies of treatment you received, or your test results. Summaries of your diagnosis, condition, treatment plan, symptoms, prognosis, or treatment progress, although they may be contained within those psychotherapy notes, typically are not protected as psychotherapy notes when they appear in other sections of your records.

​

We will not disclose psychotherapy notes to others unless you’ve given written authorization to do so, subject to narrow exceptions (for example 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 to enroll in a health plan. If you have any questions, feel free to discuss the subject with your therapist.

​

Please note that we may deny you access to psychotherapy notes if we determine that disclosure of specific information will constitute a substantial detriment to your treatment, or we will reveal the identity of persons or breach the trust or confidentiality of persons who have provided information upon an agreement to maintain their confidentiality. In very limited circumstances we may also deny you access to other portions of the records. These circumstances include when the information was obtained from others under a promise of confidentiality and access would likely reveal the source of the information, and when we determine that axis is reasonably likely to endanger the life or physical safety of either you or another person.

​

Organizational Policies

​

to facilitate the smooth and efficient operation of our practice, we engage in certain practices and policies that you should understand. You can avoid any of the following practices by discussing her concerns with us and working out an alternative:

​

• We contact our patients via telephone (which might include leaving a message on an answering machine or voicemail), or with your permission, text or email to provide appointment reminders or routine scheduling information

• We may conduct routine discussions on the way from the waiting room into the therapy office

• We may use your name and address to send you a newsletter about our practice and new services that we offer

• We may disclose your PHI to a member of your family or a close friend that relates directly to that person’s involvement in your healthcare, typically only with your permission or in the event of a true emergency

​

You should also be aware of the following policies regarding our uses and disclosures of your PHI. You cannot avoid these uses and disclosures, we should discuss any questions or concerns you might have with us:

​

• We share PHI with third-party “business associates” that perform various functions for us (for example, billing, secure email and other technology encryption, secure fax services). We have written contracts with these entities contain terms that require them to follow HIPAA regulations and protect your PHI.

 

VIII. Effective Date of Privacy Policy

​

Notice is in effect as of December 31, 2016.