NOTICE OF PRIVACY PRACTICES (HIPAA)
CONFIDENTIALITY:
Your information is generally protected and kept confidential. However, there are certain circumstances under which information may be released to other parties without your permission. It is your responsibility to review the HIPAA website for a complete list of disclosures at www.hhs.gov/ocr/privacy/index.html. The following is a partial list of my notice of privacy practices. I am required by law to maintain the privacy of protected health information, give you this notice of my legal duties and privacy practices regarding your health information, and follow the terms of my notice that currently is in effect.
FEES:
My current fee is $200 for individuals and $250 for couples (per 45 min session). In addition to weekly appointments, it is my practice to charge this amount on a pro-rated basis for other professional services you may require such as report writing, telephone contact which last longer than five minutes, attendance at meetings or consultations with other professionals which you have authorized, preparation of records or treatment summaries, or time required to perform any other psychology related service which you may request from me. If you become involved in legal proceedings which require my participation, you agree to pay for my professional time plus any additional transportation costs, which will be part of a $4000 up front retainer, no exceptions (with a ten hour minimum) prior to any court appearance, settlement conference or deposition testimony is made; any balance will be charged on the card on file. The same 48 (2 business days) cancellation policy applies to court appearances, regardless of reason for cancellation. (Due to the complexity and difficulty of legal involvement, I charge $400 per hour, for preparation prior to attendance of any legal proceeding either requested or subpoenaed, in addition to any and all travel time at billed same hourly rate; these services are not reimbursed by insurance)
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION
The following describes the ways I may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, I will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing. For Treatment. I may use and disclose Health Information for your treatment and/or to provide you with treatment-related health care services. For example, I may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside my office, who are involved in your medical care and need the information to provide you with medical care. I may contact you by phone, text or email to remind you that you have an appointment with me. I also, may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
For Payment
I may use and disclose Health Information so that others or I may bill and receive payment from you, an insurance company, or third party for the treatment and services you received. For example, I may give your health plan information about you so they will pay for your treatment or provide an authorization. When appropriate, I may share Health Information with a person who is involved in your medical care or payment for your care (e.g., family, close friend).
For Health Care Operations
I may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure my patients receive quality care and to operate and manage this office. For example, I may use and disclose information to make sure the psychiatric care you receive is of the highest quality. I, also, may share information with other entities that have a relationship with you (e.g., your health plan) for their health care operation activities.
1. Insurance:
If you are using health insurance for reimbursement of your visits, the information and your verifiable and billable mental illness diagnosis is entered into the medical information bureau (www.mib.gov), which may have consequences when applying for other insurance policies (e.g., health, life, long-term care, disability) or even a job. If your employer provides your health coverage, they may have access to your information as well.
2. Out of pocket payments
If you paid out-of-pocket for a specific item or service and did not seek reimbursement from your health insurance, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and I will honor that request. If your rate is discounted in any way, you expressly and unconditionally agree to NOT seek reimbursement from your insurance and/or NOT to apply that sum towards your insurance deductible.
3. Payment by another person/entity
If another person/entity is paying for your visits, they have the right to know if you have attended the sessions.
4. Credit card companies
I am agreeing that charges placed on my credit card for psychotherapy services are non-refundable and non-cancelable and will not be disputed by me or any party authorized on my credit card, independent of outcome.
5. Court order/subpoena/litigation
Clinicians are required to provide information in response to court orders or subpoenas. Additionally, if treatment is provided as a result of a court order, I am required to release certain information. It would be your attorney’s responsibility to claim privileges associated with the disclosure of your records. It should be noted that all electronic communication is potentially discoverable during litigation.
6. Consultation
Your clinician may consult with other professionals regarding your case. Please indicate in writing if you would like restrictions placed on what can be shared.
7. Abuse/neglect
When there is reasonable suspicion of current or previous child, adult, elderly, or disabled abuse/neglect, clinicians are required to report this information to certain authorities, persons, and agencies.
8. To avert a serious threat to health or safety
I may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
9. Death
After your death, your information remains confidential unless you provide a signed release prior to your death. However, records may be reviewed by the executor of your estate. You can request in writing that your records be purged after your death. This request needs to be discussed with your estate attorney and be notarized. It is up to the clinician’s discretion whether or not to comply with this request.
10. Business associates
I may disclose Health Information to my business associates that perform functions on my behalf or provide me with services if the information is necessary for such functions or services. For example, I may use another company to perform billing services on my behalf. All of my business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
11. Data breach notification purposes
I may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
12. Lawsuits and disputes
If you are involved in a lawsuit or a dispute, I may disclose Health Information in response to a court or administrative order. I also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
13. Public health risks
I may disclose Health Information for public health activities. These generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; and a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. I will only make this disclosure if you agree or when required or authorized by law.
14. Coroners, medical examiners and funeral directors
I may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. I also may release Health Information to funeral directors as necessary for their duties.
15. Inmates or individuals in custody
If you become an inmate of a correctional institution or under the custody of a law enforcement official, I may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
16. Workers’ compensation
I may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
17. Military and veterans
If you are a member of the armed forces, we may release Health Information as required by military command authorities. I also may release Health Information to the appropriate foreign military authority if you are a member of the foreign military.
18. Health oversight activities
I may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
19. Organ and tissue donation
If you are an organ donor, I may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation and transplantation.
20. Couples and family sessions
The couple or the family is the client and therefore if anyone in the future needs information about anyone, all parties involved will need to sign the consent to release information. I also have a “no-secrets” policy when working with couples or families. This means that while what is said in session is confidential, if a single family member communicates information outside of the session, it will be discussed with all family members involved.
21. Minors
Laws regulate that certain information may or may not be shared with the minor’s legal guardian/parent. This also may be up to the discretion of the treatment provider, especially if the disclosure would negatively affect treatment progress with the patient.
22. Natural disasters
I cannot be held responsible for information that may become exposed as a result of inclement weather.
23. Law enforcement
I may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, I are unable to obtain the person’s agreement; (4) about a death I believe may be the result of criminal conduct; (5) about criminal conduct on my premises; and (6) in an emergency.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I contact you by email or at work. To request confidential communications, you must make your request in writing. I will accommodate reasonable requests.
RIGHT TO INSPECT AND COPY
You have the right to inspect and copy only part of the medical information that is used to make decisions about your care. This includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. Of my records, you only have access to the mental status exam and diagnosis. The psychiatric diagnosis is a constant work in progress that is refined the more time the clinician spends with the patient. An initial diagnosis is frequently provisional. I may black out any other components of the note. An alternative, recommended option is to request a note summarizing your care by my practice. I will charge you the usual fees for the time it takes to deal with your request. In order to inspect and copy medical information, you must submit your request in writing. I have up to 30 days to make your protected health information available to you. I may deny your request to inspect and copy under unique circumstances. If you are denied, you may request the denial be reviewed and another licensed health care professional chosen by this practice will review your request and the denial. I will comply with the outcome of that review. I recommend you only review your records in the presence of your clinician after careful discussion.
RIGHT TO AMEND
If you feel that the Health Information I have is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. You may also write an amendment to the clinician and we will add it to your chart. I cannot erase notes that have already been written.
RIGHT TO GET NOTICE OF A BREACH
You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information I disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that I not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request in writing to your clinician. I am not required to agree to your request unless you are asking me to restrict the use and disclosure of your Protected Health Information to a health plan for payment or for health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If I agree, I will comply with your request unless the information is needed to provide you with emergency treatment.
SENDING RECORDS
It is not a good idea to release your complete psychiatric records to anyone for any reason. Routine psychiatric notes are not written for anyone other than the author and are subject to misinterpretation. Your clinician can prepare a summary of your treatment or a current psychiatric evaluation answering a specific question to a consultant. A copy can be sent to another clinician one time if you are transferring care, and they want to read your entire record. Most clinicians I know would prefer a treatment summary. If you release your entire record, be aware that it may take time to paste all past electronic communications into your chart, and you will be charged for the time it takes to paste them into the record. The fee for copying and if necessary blacking out psychotherapy notes is $1 a page. I will charge you the usual fees for the time it takes to deal with your request. In the event your account is past due, records will not be released until the account is brought up to date.
RIGHT TO AN ACCOUNT OF NON-STANDARD DISCLOSURES
You have the right to request a list of the disclosures we made of medical information about you for purposes other than treatment, payment, or health care operations or for which you provided written authorization. You must submit your request to our practices and indicate the time period for which you want to receive a list of disclosures that is no longer than six years. This excludes the Department of Social Security.
PUBLICATION
I may use information from your records for research, teaching, and publication purposes. I will make it anonymous and keep your identity protected.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT
1. Individuals involved in your care or payment for your care
Unless you object, I may disclose to a member of your family, a relative, a close friend, or any other person you identify your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, I may disclose such information as necessary if I determine that it is in your best interest based on my professional judgment.
2. Disaster relief
I may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
- Uses and disclosures of Protected Health Information for marketing purposes
- Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this notice or the laws that apply to me will be made only with your written authorization. If you do give me authorization, you may revoke it at any time by submitting a written revocation and I will no longer disclose Protected Health Information under the authorization. However, disclosure that I made in reliance on your authorization before you revoked it will not be affected by the revocation.
