HIPAA Privacy Notice

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    HIPAA Privacy Notice

    CONNECTICUT HIPAA NOTICE FORM

    Notice of 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. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations The Center may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. This is done by different methods as appropriate including unencrypted e-mail and texting. These methods do have an inherent risk depending on the security and data safeguarding measures that are applied to the data. Unencrypted e-mail and text messaging may be used by the clinicians at The Southfield Center to communicate with you regarding the client noted on this form. Please notify the Clinician if you would prefer not to receive communication by these methods. Also our scheduling system at The Southfield Center is equipped with a notification system that will send text message and email reminders of appointments. Please let us know if you do not want to be notified in this manner. To help clarify these terms, here are some definitions. For the purposes of this form, “The Center” refers to the clinician(s) at the Southfield Center with whom you are working:
    • PHI” refers to information in your health record that could identify you.
    • Treatment, Payment and Health Care Operations
      • Treatment is when The Center provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when The Center consults with another health care provider, such as your family physician or another mental health professional.
      • Payment is when The Center obtains reimbursement for your healthcare. Examples of payment are when The Center discloses 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, center, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
    • Disclosure” applies to activities outside of my [office, center, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
    II. Uses and Disclosures Requiring Authorization The Center may use or disclose PHI for purposes outside of treatment, payment, or 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 The Center is asked for information for purposes outside of treatment, payment or health care operations, The Center will obtain an authorization from you before releasing this information. The Center will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes The Center has made about our conversation during a private, group, joint, or family counseling session, which The Center has 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) The Center has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization The Center may use or disclose PHI without your consent or authorization in the following circumstances:
    • Child Abuse – If The Center, in the ordinary course of my profession, has reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had nonaccidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then The Center must report this suspicion or belief to the appropriate authority.
    • Adult and Domestic Abuse – If The Center knows or in good faith suspects that an elderly individual or an individual, who is disabled or incompetent, has been abused, The Center may disclose the appropriate information as permitted by law.
    • Health Oversight Activities – If the Connecticut Board of Examiners is investigating my practice, the board may subpoena records relevant to such investigation.
    • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and The Center 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 The Center believes in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, The Center may disclose the appropriate information as permitted by law.
    • Worker’s Compensation – The Center 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.
    IV. Patient’s Rights and Mental Health Professional’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. However, The Center is 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, The Center 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 my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. The Center may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, The Center 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. The Center may deny your request. On your request, The Center 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, The Center 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.
    Mental Health Professional’s Duties:
    • The Center is 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.
    • The Center reserves the right to change the privacy policies and practices described in this notice. Unless The Center notifies you of such changes, however, The Center is required to abide by the terms currently in effect.
    • If The Center revises these policies and procedures, The Center will provide you with a revised form in person or by mail.
    V. Complaints If you are concerned that The Center has violated your privacy rights, or you disagree with a decision The Center made about access to your records, you may contact the State of Connecticut, Dept. of Public Health (860-509-7603). 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. VI. Effective Date, Restrictions, and Changes to Privacy Policy
  • The Center reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that The Center maintains. The Center will provide you with a revised notice by hand or by U.S. mail.

    After you review this form, The Center will ask you to sign that you have read and understand these privacy policies on a form that will be maintained in your client file.