THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Privacy is a very important concern for all those who come to this office. It is also complicated, because of the many federal and state laws and professional ethics. Because the rules are so complicated, some parts of this notice are very detailed. If you have any questions, we will be happy to help you understand the procedures and your rights.
A. Introduction: To clients
B. What we mean by your medical information
C. Privacy and the laws about privacy
D. How your protected health information can be used and shared
1. Uses and disclosures with your content
a. The basic uses and disclosures: For treatment payment and health care
b. Other uses and disclosures in health care
2. Uses and disclosures that require your authorization
3. Uses and disclosures that don’t require your consent or authorization
a. When required by law
b. For law enforcement purposes
c. For public health activities
d. Relating to decedents
e. For specific government functions
f. To prevent a serious threat to health or safety
4. Uses and disclosures when you have an opportunity to object
5. An accounting of disclosures we have made
E. Your rights concerning your health information
F. If you have questions or problems
This notice will tell you how we handle your medical information. It tells how we use this information here in this office, how we share it with other professionals and organizations, and how you can see it. If you have any questions or want to know more about anything in this notice, please let us know.
Each time you visit any doctor’s office, hospital, clinic or other health care provider, information is collected about you and your physical and mental health. It may be information about your past, present, or future health or conditions, or the tests and treatment you got from us or from others, or about payment for health care. The information we collect from you is called “PHI,” which stands for “protected health information.” This information goes into your medical or health care records in our office.
In this office, your PHI is likely to include these kinds of information:
PHI is used for many purposes. For example, we may use it:
Although your health care records in our office are your physical property, the information belongs to you. You can read your records, and if you want a copy we can make one for you (but we may charge you for the costs of copying and mailing, if you want it mailed to you.) If you find anything in your records that you think is incorrect or believe that something important is missing, you can ask us to amend (add information to) your records, although in some rare situations we don’t have to agree.
We are required to tell you about privacy because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPPA). HIPPA requires us to keep your PHI private and to give you this notice about our legal duties and privacy practices. We will obey the rules described in this notice. If we change our privacy practice, it will apply to all the PHI we keep.
Except in some special circumstances, when we use your PHI in this office or disclose it to others, we share only the minimum necessary PHI needed for those other people to do their jobs. The law gives you a right to know about your PHI, to know how it is used, and to have a say in how it is shared.
Mainly, we will use and disclose your PHI for routine purposes to provide for your care, and we will explain more about these below. For other uses, we must tell you about them and ask you to sign a written authorization form. However, the law also says that there are some uses and disclosures that don’t need your consent or authorization.
Uses and disclosures with your consent: After you have read this notice, you will be asked to sign a separate consent form to allow us to use and share your PHI. In almost all cases we intend to use your PHI here or share it with other people or organizations to provide treatment to you, arrange for payment for our services, or some other business functions called “health care operations.” In other words, we need information about you and your condition to provide care to you. You must agree to let us collect the information, use it, and share it to care for you properly. Therefore, you must sign the consent form before we begin to treat you. If you do not agree and consent, we cannot treat you.
The basic uses and disclosure: For treatment, payment and health care operations – Next, we will tell you more about how your information will be used for treatment, payment, and health care operations.
For Treatment: We use your medical information to provide you with psychological treatments or services. These might include individual, family, or group therapy; psychological, educational, or vocational testing; treatment planning; or measuring the benefits of the services. We may share your PHI with others who provide treatment to you. We are likely to share your information with your personal physician and psychiatrist. If you are being treated by a team, we can share some of your PHI with the team members, so that the services you receive will work best together.
For Payment: We may use your information to bill you, your insurance, or others, so we can be paid for the treatments provided to you. We may contact your insurance company to find out exactly what your insurance covers. We may have to tell them about your diagnoses, what treatments you have received, and the changes we expect in your conditions. We will need to tell them about when we met, your progress, and other similar things.
For Health Care Operations: Using or disclosing your PHI for health care operations goes beyond our care and your payment. For example, we may use your PHI to see where we can make improvements in the care and services we provide.
Appointment reminders: We may use and disclose your PHI to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or your work, or you prefer some other way to reach you, we usually can arrange that. Just let us know what works best for you. Treatment alternatives: We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of help to you.
Other benefits and services: We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
Research: We may use or share your PHI to do research to improve treatment-for example, comparing two treatments for the same disorder, to see which works better or faster or costs less. In all cases, your name, address, and other personal information will be removed from the information given to researchers. If they need to know who you are, we will discuss the research project with you, and we will not send any information unless you sign a special authorization form.
If you want to use your information for any purpose besides those described above, we need your permission on an authorization form. If you do allow us to use or disclose your PHI, you can cancel that permission in writing at any time. We would then stop using or disclosing your information for that purpose. Of course, we cannot take back any information we have already disclosed or used with your permission.
The law lets us use and disclose some of your PHI without your consent or authorization in some cases. Here are some examples of when we might do this.
This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.