THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION MAY BE 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
protected health information
treatment, payment, and health care operations
purposes with your
. To help clarify these terms, here are some definitions:
refers to information in the health record that could identify the patient.
Treatment, Payment, and Health Care Operations
is when we provide, coordinate, or manage health care and other services
related to this health care. An example of treatment is when we consult with another
health care provider, such as your family physician or another mental health professional.
is when we obtain reimbursement for health care. Examples of payment are
when we disclose the
to your health insurer to obtain reimbursement for health care
or to determine eligibility or coverage.
Health Care Operations
are activities that relate to the performance and operation of
our 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.
applies only to activities within our office, such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies the patient.
” applies to activities outside of our office, such as releasing, transferring, or
providing access to information to other parties.
” is your written permission to disclose confidential mental health information.
All authorizations to disclose must be on a specific legally required form.
II. Other Uses and Disclosures Requiring Authorization
We may use or disclose
for purposes outside of treatment, payment or health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. You may revoke all such authorizations (of
) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (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 Disclosures with Neither Consent nor Authorization
We may use or disclose
without your consent or authorization in the following circumstances:
---If we believe or have reason to believe that a child is a victim of child abuse or neglect,
we must file a report with the appropriate authorities, usually the local child protection service. Once such
such a report is filed, additional information may be required.
Adult and Domestic Abuse--
If we believe or have reason to believe that an individual is an endangered
adult, this report must be reported to the appropriate authorities, usually the adult protective services unit.
Once the report is filed, additional information may be required.
Health Oversight Activities--
If the Indiana Attorney General’s Office is conducting an investigation into
our practices, then we are required to disclose
upon receipt of a subpoena.
Judicial and Administrative Proceedings--
If the patient is involved in a court proceeding and a request
is made for information about the professional services provided and/or the records thereof, such
information is privileged under state law, and we will not release it without the written authorization of you
or your legally appointed representative or a court order. This privilege does not apply when the patient is
being evaluated for a third party or where the evaluation is court ordered. You will be informed of it.
Serious Threat to Health or Safety--
If the patient communicates an actual threat of physical violence
to cause serious injury or death against a reasonably identifiable victim or victims or evidences conduct or
makes statements indicating imminent danger that the patient will use physical violence or other means
to cause serious personal injury or death to others, we may be required to disclose information to prevent
that harm from occurring. If we have reason to believe that the patient presents an imminent, serious risk
of physical harm or death to himself/herself, we may need to disclose information to protect him/her. In
both cases, we will only disclose what we believe to be the minimum information necessary. Actions may
include notifying the potential victim, contacting the police, or seeking to hospitalize the patient.
We may disclose protected health information regarding the patient 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. Patient’s Rights and Practitioners’ Duties
Right to Request Restrictions--
There is the right to request restrictions on certain uses and disclosures
of protected health information. However, we are not required to agree to a restriction requested.
Right to Receive Confidential Communications by Alternative Means and at Alternative
There is the right to request and receive confidential communications of
means and at alternative locations. For example, you may not want a family member to know about your
treatment. On your request, bills can be sent to another address.
Right to Inspect and Copy--
There is the right to inspect or obtain a copy (or both) of
in our mental
health and billing records used to make decisions about the patient for as long as the
is maintained in
the record. Your access to
may be denied under certain circumstances, some of which you may have
reviewed. If you ask, the details of the request and denial process will be discussed with you.
Right to Amend
There is the right to request an amendment of
for as long as the
in the record. Your request may be denied. If you ask, the details of the amendment process will be
discussed with you.
Right to an Accounting--
There is the right to receive an accounting of disclosures of
. On your
request, the details of the accounting process will be discussed.
We are required by law to maintain the Privacy of
and to provide you with a notice of our legal duties
and privacy practices with respect to
* We reserve the right to change the privacy policies and practices described in this Notice. Unless we
notify you of such changes, however, we are required to abide by the terms currently in effect.
* If we revise these policies and procedures, you will be handed the revised Notice at the next session.
If you are concerned that we have violated these privacy rights, or you disagree with a decision we made about access to the records, you may contact Beth L. Fineberg, Ph.D. or William H. Cook, LCSW at this office.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Those listed above can provide you with the appropriate address upon request.
THIS NOTICE WILL GO INTO EFFECT APRIL 14, 2003.
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.