Privacy Policies

Pennsylvania Notice Form  

Notice of Psychologists’ 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.  

1. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI) for treatment, payment,  and health care operations with your consent. To help clarify these terms, here are some  definitions:  

 “PHI” refers to information in your health record that could identify you.   “Treatment, Payment, and Health Care Operations”  

o 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.  

o Payment is when I obtain reimbursement for your healthcare. Examples  of payment are when I disclose your PHI to your health insurer to obtain  reimbursement for your healthcare or to determine eligibility or coverage.  

o 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 such as sharing, employing,  applying, utilizing, examining, and analyzing information that identifies you.   “Disclosure” applies to activities outside of my office such as releasing,  transferring, or providing access to information about you to other parties.  

1. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and 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 I am asked for information for purposes outside of  treatment, payment, and 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 conversation 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 than PHI. I do not necessarily keep psychotherapy notes on all  patients or for all sessions.  

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, and the law provides the insurer the right  to contest the claim under the policy.  

III. Uses and Disclosures with Neither Consent nor Authorization  I may use or disclose PHI without your consent or authorization in the following  circumstances.  

 Child Abuse: If I have reasonable cause, on the basis of my professional  judgment, to suspect abuse of children with whom I come into contact in my  professional capacity, I am required by law to report this to the Pennsylvania  Department of Public Welfare.  

 Adult and Domestic Abuse: If I have reasonable cause to believe that an older  adult is in need of protective services (regarding abuse, neglect, exploitation or  abandonment), I 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 I provided you  or the records thereof, such information is privileged under state law, and I will  not release the information without your written consent, 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 express a serious threat, or intent to  kill or seriously injure an identified or readily identifiable person or group of  people, and I determine that you are likely to carry out the threat, I 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, I will be  required to file periodic reports with your employer, which shall include, where  pertinent, history, diagnosis, treatment, and prognosis.  

 Impaired Driving: If it apparent that you are unable to safely operate a vehicle at  the time of your departure from the office, your psychologist is obligated to  inform the police in order to protect the safety of the general public. Likewise, if  it is apparent that you are unable to safely operate a vehicle for medical or other  reasons and disclose that you continue to drive, your psychologist may be  required to notify authorities to insure public safety. 

1. Patient’s Rights and Psychologist’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, 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.  Upon 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 my 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 for which you have neither provided consent nor authorization  (as described in Section III of this Notice). 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.  

 Right to Notification of any Breach: If there is a breach of your confidentiality,  then I must inform you as well as Health and Human Services. A breach means  that information has been released without authorization or without legal authority  unless I (the covered entity) can show that there was a low risk that the PHI has  been compromised because the unauthorized person did not view the PHI or it  was de-identified.  

 Self-Pay Right to Restriction: If you are self-pay, then you may restrict the  information sent to insurance companies.  

 Most uses and disclosures of psychotherapy notes and of protected health  information for marketing purposes and the sale of protected health information  require an authorization. Other uses and disclosures not described in the notice  will be made only with your written authorization. You must sign an authorization  (release of information form) for releases unless it is for purposes already  mentioned in this Privacy Notice (such as mandated reporting of child abuse,  reporting of elder abuse, reporting of impaired drivers, etc.).  

 Right of Electronic Record: You have a right to receive a copy of your Protected  Health Information in an electronic format or (through a written authorization)  designate a third party who may receive such information. 

Psychologist’s Duties:  

 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 able to abide by the  terms currently in effect.  

1. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to  your records, or have other concerns about your privacy rights, you may contact me.  

If you believe that your privacy rights have been violated and wish to file a complaint,  you may send your written complaint to me.  

You may also send a written complaint 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.