Notice of Privacy Practices
Notice of Policies and Practices to Protect the Privacy of Your Health Information
This notice describes how clinical and medical information about you may 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
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these term are some definitions:.
II.Uses and Disclosure Requiring Authorization.
- I may use or Disclose PHI for purposes outside of treatment, payment, or health care operations when our 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 or health care operations, I will obtain an authorization from you before releasing this information. As general rule, I do not release my personal Psychotherapy Notes. “Psychotherapy Notes” are not notes I have made about our conversation during a private, group, couple’s or family counseling session, which I have kept separate from the rest of your medical record. The notes are given a greater degree of protection than PHI.
- You may revoke the authorization for release of your PHI anytime, provided the revocation is in writing. You may not revoke an authorization to the extent that (1)I have relied on that authorization;(2)if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III.Uses and Disclosure with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following:
- Child Abuse- If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.
- Adult and Domestic Abuse- If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such or elder person, other than by means, or has been neglected or exploited, I must report that believe to the appropriate authority.
- Health Oversight Activities- If I am the subject of an inquiry by my licensing board, I may be required to disclose protected health information regarding you in proceedings before the Board. I will attempt to inform you and explain what has to be revealed.
- Judicial and Administrative Proceeding- If you are involved in the court proceeding and 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 information without written consent or 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 I determine, or pursuant to the standards of my profession should determine, that you present a serious danger or violence to yourself or another, I may disclose information in order to provide protection against us danger for you or the intended victim.
- Worker’s Compensation- I 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.Your Rights and My Duties.
- Right to Request Restrictions – You have the right to request restrictions uses and disclosures of protected health information. However, I am not required to agree to restriction you request.
- Right to Receive Confidential Communications by Alternative Means and Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and alternative locations,(For example, you may not want a family member to know that you are seeing me. On your request, I not leave messages for you on your home answering machine, as long as I have an alternative way of contacting you.)
- 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 record used to make decision about you for as long as the 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 and 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. On your request, I will discuss with you the details of 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.
- 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 required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will discuss these changes with you during a session.
If you are concerned that I have violated your privacy rights, or you agree with a decision I made about access to your records, you may contact me, James H. Bird, LCSW, at 404-262-1819. 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.
VI..Effect Date, Restrictions, and Changes to Private Policy.
This notice will go into effect on May 19, 2003.
I reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that I maintain. If this should occur, I will provide you a written copy of the revised notice.