Pennsylvania Notice Form

 
 
 
 

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 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 without your authorization. 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

Treatment is when your therapist provides or coordinates your health care information and other services related to your health care. An example of treatment would be when the psychologist consults with another health care provider, such as your family, physician or another therapist.

Payment is when your psychologist obtains reimbursement for your healthcare. Examples of payment operations are; disclosures of 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 the practice. Examples of health care operations are the 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 such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you

 

 Disclosure applies to activities outside of treatment, such as releasing transferring or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Your psychologist 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 the psychologist is asked information for the purposes outside of treatment, payment and health care operations, an authorization will be obtained from you prior to releasing this information. Authorization will also be requested before using or disclosing your psychotherapy notes except in very limited circumstances. Psychotherapy notes are notes that have been made about our conversation during private, joint, group or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. Authorization is not needed if your psychotherapy notes are to be used: by the originator for treatment purposes, for training, to defend a legal action brought by you, or to disclose to certain health oversight agencies as permitted by law.

You may revoke all such authorization (of PHI or psychotherapy notes) at any time, provided such revocation is in writing. You may not revoke an authorization to the extent that (1) your psychologist has relied on that authorization; or if (2) 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 without Authorization

Your PHI may be used or disclosed without your authorization in the following circumstances:

  •   Child Abuse: If reasonable cause is present, on the basis of professional judgment, to suspect abuse of children it is required, by law that a report be made to the Pennsylvania Department of Public Welfare.

  •   Adult and Domestic Abuse: If reasonable cause is present to believe that an older adult is in need or protective services (regarding abuse, neglect, exploitation or abandonment), a report to the local agency which provides protective services may be made.

  •   Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services provided you or the records thereof, such information is privileged under state late and will not be release without your 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 you express a serious threat or intent to kill or seriously injure an identified or readily identifiable person or group of people and it is determined that you are likely to carry out this threat, reasonable measures to recent

 

harm must be taken. Reasonable measures may include directly advising the potential

victim of the threat or intent.
 Workers’ Compensation: If you file a worker’s compensation claim, your psychologist

will be required to file periodic reports with your employer which shall include pertinent history, diagnosis, treatment and prognosis.

IV. Patients Rights and Treatment Responsibilities:

Patients’ Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your therapist is not requires 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 you are seen for therapy. Upon your request, we 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 mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your request may be denied. On your request, the details of the amendment process will be discussed with you

  •   Right to an Accounting – You generally have the right to receiving an accounting of disclosures of PHI for which you have neither provided consent not authorization (as described in Section III of this Notice). On your request, the details of the accounting process will be discussed with you.

  •   Right to a Paper Copy – You have the right to obtain a paper copy of this notice upon request, even if you have agreed o receive the notice electronically.

    Therapist’s Responsibilities:

     Your therapist is required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI.

     Your therapist reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, we are required to abide to the terms currently in effect.

    If these policies and procedures are revised, you will be notified about the changes via a written notice of revision.

V. Complaints:

If you are concerned that your privacy right shave been violated, or you disagree with a decision made about access to your records, you may discuss this with your provider.

 

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services or the Pennsylvania Board of Psychology.

You will not be retaliated against for filing a complaint.

VII. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on our first evaluation.
If this is notice is revised in any way, you will be notified within 30 days.