Hooray! Starting April, 2003, a new law named HIPAA established greater
safeguards for patient privacy, and the law requires that I provide to all
clients a description of how the rules of privacy are applied in my practice.
This document serves as that notice.
law protects the privacy of all communications between a patient and a
psychologist or counselor. In most situations, I can only release information
about your treatment to others if you sign a written Authorization form that
meets certain legal requirements imposed by HIPAA. We will go over that form
together if there ever is specific need for it.
there are certain other situations that require only that you provide written
consent one time, for example at the start of therapy. I will be asking for
you to give consent for me to disclose certain information about you, which is
necessary for me to work effectively and to get paid. The following six points
explain the types of disclosure that I generally need for every client.
occasionally find it helpful to consult other health and mental health
professionals about a case. During a consultation, I make every effort to
avoid revealing the identity of my patient. The other professionals are also
legally bound to keep the information confidential. If you donít object, I
will not tell you about these consultations unless I feel that it is important
to our work together. I will note all consultations in your Clinical Record.
practice with other mental health professionals and I employ administrative
staff. In most cases, I need to share protected information with these
individuals for both clinical and administrative purposes, such as scheduling,
billing and quality assurance. All of the mental health professionals and
staff members are bound by the rules of confidentiality. When we contact you
for administrative purposes, such as billing or scheduling appointments, we
will use the telephone numbers and mailing address you provide, and we will
use discretion when leaving any messages for you. You may direct us to even
further restrict disclosure, for example not leaving messages on your machine.
you want your insurance to pay or reimburse for my services, I will provide it
with information relevant to the services that I provide to you. Generally, I
am required to provide a clinical diagnosis, and sometimes I am required to
provide additional clinical information such as treatment plans or summaries,
or copies of your entire Clinical Record. In such situations, I will make
every effort to release only the minimum information about you that is
necessary for the purpose requested. This information will become part of the
insurance company files and will probably be stored in a computer. Though the
insurance companies are required by HIPAA to treat patient information in a
confidential manner, I have no control over what they do with it once it is in
their hands. I will provide you with a copy of any report I submit, if you
Collection: If your
account has not been paid for more than 60 days and arrangements for payment
have not been agreed upon, I have the option of using legal means to secure
the payment. This may involve hiring a collection agency or going through
small claims court which will require me to disclose otherwise confidential
information. In most collection situations, the only information I release
regarding a patientís treatment is his/her name, the nature of services
provided, and the amount due.
privacy in psychotherapy is often crucial to successful progress, particularly
with teenagers, it is my policy to request an agreement from parents that they
consent to give up their access to their childís records. I will provide
parents only with general information about the progress of the childís
treatment, and his/her attendance at scheduled sessions, unless I find an
imminent threat of harm to self or others.
Safety: If any
patient threatens to harm himself/herself or others, I may be obligated to
seek hospitalization for him/her, or to contact family members or others who
can help provide protection.
are also some situations where I am permitted or required by law to disclose
information without either your consent or Authorization: These situations are
unusual in my practice. The following six points explain these unusual
abuse: If I
know or suspect that a child under the age of 18 has been abused or neglected,
the law requires that I file a report with the appropriate governmental
agency, usually the Alabama Department of Human Resources. Once such a report
is filed, I may be required to provide additional information.
abuse: If I
know that an elderly or disabled adult has been abused, neglected, exploited,
sexually or emotionally abused, the law requires that I file a report with the
appropriate governmental agency, usually the Alabama Department of Human
Resources. Once such a report is filed, I may be required to provide
Safety: If I
believe that disclosing information about you is necessary to prevent or
lessen a serious and imminent threat to the health and safety of an
identifiable person(s), I may disclose that information, but only to those
reasonably able to prevent or lessen the threat.
If you are involved in a court proceeding and a request is made for
information concerning your diagnosis and treatment, such information is
protected by the psychologist-patient privilege law. I cannot provide any
information without your (or your legal representativeís) written
authorization, or a court order. If
you are involved or contemplating litigation, you should consult with your
attorney to determine whether a court would be likely to order me to disclose
information. However, if a patient files a complaint or lawsuit against me, I
may disclose relevant information regarding that patient in order to defend
oversight activities: If
a government agency is requesting the information for health oversight
activities, I am required to provide it for them.
a patient files a workerís compensation claim, I may disclose information
relevant to that claim to the patientís employer or the insurer.
one of these situations arises, I will make every effort to fully discuss it
with you before taking any action and I will try to limit my disclosure to
what is necessary.
should be aware that, pursuant to HIPAA, I keep Protected Health Information
about you in two sets of professional records. One set constitutes your
Clinical Record. It includes information about your reasons for seeking
therapy, a description of the ways in which your problem impacts on your life,
your diagnosis, the goals that we set for treatment, your progress towards
those goals, your medical and social history, your treatment history, any past
treatment records that I receive from other providers, reports of any
professional consultations, your billing records, and any reports that have
been sent to anyone, including reports to your insurance carrier. If you
provide me with an appropriate written request, you have the right to examine
and/or receive a copy of your records, except in unusual circumstances that
involve danger to you or others. In those situations, you have a right to have
your record sent to another mental health provider. If I refuse your request
for access to your records, you have a right of review, which I will discuss
with you upon request. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, I
recommend that you initially review them in my presence, or have them
forwarded to another mental health professional so you can discuss the
In addition, I may also keep a set of Psychotherapy
Notes. These notes are for my own use and are designed to assist me in
providing you with the best treatment. While the contents of Psychotherapy
Notes vary from client to client, they can include the contents of our
conversations, my analysis of those conversations, and how they impact on your
therapy. They also contain particularly sensitive information that you may
reveal to me that is not required to be included in your Clinical Record.
These Psychotherapy Notes are kept separate from your Clinical Record. While
insurance companies can request and receive a copy of your Clinical Record,
they cannot receive a copy of your Psychotherapy Notes without your
Authorization. Insurance companies cannot require your Authorization as a
condition of coverage nor penalize you in any way for your refusal.
You may examine and/or receive a copy of your Psychotherapy Notes
unless I determine that such disclosure would be reasonably likely to endanger
provides you with several new or expanded rights with regard to your Clinical
Record and disclosures of protected health information. These rights include
requesting that I amend your record; requesting restrictions on what
information from your Clinical Record is disclosed to others; requesting an
accounting of most disclosures of protected health information that you have
neither consented to nor authorized; determining the location to which
protected information disclosures are sent; having any complaints you make
about my policies and procedures recorded in your records; and the right to a
paper copy of this Notice form and Agreement. I am happy to discuss any of
these rights with you, and our office manager will provide you with the forms
necessary for you to request any of these activities.
If you have questions about this notice, disagree
with a decision I make about access to your records, or have other concerns
about your privacy rights, you may discuss it with me. If you prefer you may
contact our office manager, Michelle Gurley.
You may also send a written complaint to the
Secretary of the U.S. Department of Health and Human Services, 200
Independence Avenue SW, Washington, D.C. 20201.
You have specific rights under the Privacy Rule.
I will not retaliate against you for exercising your right to file a
notice will go into effect on April 15, 2003.
I reserve the right to change the terms of this notice and to make the new notice provisions effective for all Protected Health Information that I maintain. I will provide you with a revised notice by mail.