Notice of Privacy Practices for Protected Health Information

Clinical Psychology Associates

Notice of Clinic 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 IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Clinical Psychology Associates (THE CLINIC) 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" refers to information in your health record that could identify you.

"Treatment, Payment and Health Care Operations"

– Treatment is when the Clinic provides, coordinates, or manages your health care and other services related to your health care. For example, consultation with another provider such as your family physician or another psychologist.

– Payment is when the Clinic obtains reimbursement for your healthcare. Examples of payment are when the Clinic discloses your PHI to your insurer to obtain reimbursement for your care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of the Clinic 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 the Clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside of the Clinic such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

The Clinic 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes your therapist may have made about conversations during a private, group, joint, 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.

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) the Clinic has 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 contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

The Clinic may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If a practitioner has reasonable cause to suspect that a child seen in the course of his or her professional duties has been abused or neglected, or has reason to believe that a child seen in the course of his or her professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, the practitioner must report this to the relevant county department, child welfare agency, police, or sheriff’s department.

Adult and Domestic Abuse: If the practitioner believes that an elderly person has been abused, or neglected, he or she may report such information to the relevant county department or state official of the long-term care ombudsman.

Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that the Clinic release records to them in order for the Psychology, Medical, or Social Worker Examining Boards to investigate a complaint, we must comply with such a request.

Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release the information without written authorization from you or your personal or legally-appointed representative, or a 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 a practitioner has reason to believe, exercising professional care and skill, that you may cause harm to yourself or another, the practitioner must warn the third party and/or take steps to protect you, which may include instituting commitment proceedings.

Worker’s Compensation: If you file a worker's compensation claim, the Clinic may be required to release records relevant to that claim to your employer or its insurer and may be required to testify.

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 about you. However, the Clinic is 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 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 that you are receiving services at the Clinic. 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, we will discuss with you the details of the request 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. We may deny your request. On your request, we 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 regarding you. On your request, we 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 this notice from the Clinic upon request, even if you have agreed to receive the notice electronically.

Clinic’s Duties:

The Clinic is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
The Clinic reserves 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 our policies and procedures, we will post a notice of this revision in our offices and on our website. Such a notice will also appear on billing statements for two months following the policy revision.

V. Complaints

If you are concerned that the Clinic has violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Connie Thompson, HIPAA Compliance Officer, at 262-534-7777. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003.