HIPAA - Notice of Privacy Practices
Effective date: August 20, 2011
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.
Aubra Taylor, MA, LMFT-A is a mental health therapist with Affinity Mental Health in Seattle, WA. Aubra Taylor is also the security officer and the privacy officer for Affinity Mental Health. If you need to speak to the security officer or the privacy officer, please call 206.414.1717 or email ataylor@affinitymentalhealth.com.
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you is personal. I am committed to protecting the privacy of your health information by complying with all applicable federal and state privacy and confidentiality requirements. According, I have developed polices, enhanced the controls over my computers and other systems which access and store health data, and have received education about protecting your health information. I am required by law to maintain the privacy of your health information and to provide you with this notice of my legal duties and privacy practices.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
As your therapist, 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 terms, here are some definitions:
“PHI”, or protected health information is information in your health record that could identify you.
“Treatment, Payment, and Health Care Operations”:
“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.
“Payment” is when I obtain monetary payment or insurance reimbursement for your healthcare. Examples of payment are when I disclose 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, 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.
“Appointment Reminders” I may contact you to remind you to obtain preventative health services or to inform you of treatment alternatives and/or health related benefits and services that may be of interest to you.
II. Uses and Disclosures Requiring Authorization
I 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 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.
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. Other decisions about a few narrow exceptions to confidentiality have to be made by the psychologist. These may include the mandated reporting of child abuse, the duty to warn or protect when there is imminent danger to the safety of an identifiable third person, or whether or not to report elder abuse or the abuse of a vulnerable adult.
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 consent the claim under the policy.
As Required By Law: I will disclose health information about you when required to do so by federal, state or local law.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Abuse or Neglect: I may disclose protected health information to a government authority that is authorized by law to receive reports of abuse or neglect of a child or vulnerable adult.
Serious Threat to Health or Safety: If you communicate a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim, or if a member of your family or someone who knows you well has reason to believe you are capable of and will carry out the threat, I must make reasonable efforts to communicate this threat to the potential victim and to a law enforcement agency. I also may disclose information about you necessary to protect you from a threat to commit suicide.
Organ and Tissue Donation: If you are an organ donor I may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, I may release health information about you as required by military command authorities. I may also release health information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation: I may disclose your protected health information to comply with workers’ compensation law and other similar programs that provide benefits for work related injuries or illness.
Health Oversight Activities: I may disclose health information to a health oversight agency (such as the Minnesota Board of Psychology) for activities authorized by law. Examples of oversight activities include 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.
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 may also release health information to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: I may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. I may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information it will only be released with written authorization, or a court order. This privilege does not apply when you are being evaluated by a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case. In addition, I may release health information to defend my practice in the case of a lawsuit.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may release health information about you to the correctional institution or law enforcement official. This release would be 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) for the safety and security of the correctional institution.
Business Associates: Business associates are individuals who do not provide health care services, but who have a legitimate need for a limited amount of Protected Health Information. The term “business associates” could include computer consultants, attorneys hired by your privacy officer, billing services, or others. I require business associates to agree in writing to contract terms designed to appropriately safeguard your information.
IV. 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. 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 o 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 your are seeing me. On your request, I will send your bills to another address.)
Right to Inspect and Copy – You have the right o inspect or obtain a copy (or both) of PHI (and psychotherapy notes) 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 directed 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.
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 required to abide by the terms currently in effect.
V. Changes to this notice
We are required to abide by the terms of our Notice of Privacy Practice currently in effect. We reserve the right to change this Notice of Privacy Practice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our waiting area and give a copy to active clients. The notice will have the effective date listed on the top of the first page.
VI. Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact a therapist of your choosing to discuss your concern further.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You will not be denied service or be treated in a negative manner in response to filing a complaint.
HSQA Complaint Intake
Post Office Box 47857
Olympia, WA 98504-7857
Local: 360.236.4700
Email: HSQAComplaintIntake@doh.wa.gov
I understand and have received a copy of Affinity Mental Health’s HIPAA Notice of Privacy Practices.
Printed:
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Printed: (if there is a 2nd party)
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Signed:
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Signed: (if there is a 2nd party)
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If you have any questions for Affinity Mental Health, it’s privacy office, or it’s security office, please contact Aubra Taylor at 206.414.1717 or email ataylor@affinitymentalhealth.com.
Affinity Mental Health, Inc.
“Let’s Get Started”
206.414.1717
info@StartingTherapy.com
Downtown Seattle
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