HIPAA Notification Form
MICHELE D. GOSS, Ph.D.
A SUMMARY OF YOUR PRIVACY RIGHTS UNDER HIPAA THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INOFRMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
As a rule, I will disclose no information obtained from your contacts with me, or the fact that you are my client, except with your written consent. However, there are some important exceptions to this rule of confidentiality – some arising from my office policies, some required by law.
If you wish to receive health services from me, then under the Federal HIPAA regulations, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I. Uses and Disclosures Requiring Authorization or Consent
I may need to use or disclose your protected health information (PHI) for treatment, payment and health care operations purposes. This will require your consent in advance, either at the onset of our relationship or at the time of the need for disclosure arises. You may revoke your permission to release PHI, in writing, at any time, by contacting me. If there is an emergency and I cannot ask you permission, I am allowed to share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you. Mental Health Medical Records is the term used for my formal record of the services provided to you, and contain the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports.
- "Therapy notes" are notes I have made about our conversation during a private, group, joint, or family session, which I have kept separate from the rest of your medical record. (Under HIPAA Regulations, such notes are given a greater degree of protection that the PHI or formal record, and they are considered my own private communication. However, state law does not make this distinction, and these are included in the category of "protected health information" which can be released without your consent in circumstances such as those described in the next section.
II. Users and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances if legally required:
Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately to the Department of Social Services.
Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by law to immediately make a report and provide relevant information to the Department of Welfare of Social Services.
Health Oversight: State law requires that I report misconduct by a health care provided of my own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, I am required to explain to you how to make such a report if you describe unprofessional conduct by another mental health provider. If you are yourself a health care provider, I am required by law to report that you are in treatment if I believe that your condition places the public at risk. State Licensing Boards have the power, when necessary, to subpoena relevant records.
Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without your written authorization, or a court order. If I receive subpoena for records or testimony, I will notify you and you can file a motion to quash (the block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court of the appropriate jurisdiction. In this state, parents’ therapy records may not be used as evidence in child custody cases. However, therapy information or records are not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be "necessary for the proper administration of justice." The state has not statute granting therapist-patient privilege in criminal cases. The protections of privilege also do not apply if I do an evaluation 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: Under state law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victims(s), if under 18; 2) notifying a law enforcement officer; or 3) seeking your hospitalization. By policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.
Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant healthcare information to you, your employer, the insurer, or a certified rehabilitation provider.
Records of Minors: This state has a number of laws that limit the confidentiality of the records of minors. For example, parents regardless of custody may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors. Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.
To help clarify the terms, here are some definitions: "PHI" (Protected Health Information) refers to information in your health record that could identify you. "Treatment, Payment and Health Care Operations"
- Payment is when I obtain reimbursement for your healthcare. Examples of disclosure for payment purposes are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Treatment is when I provide, coordinate or manage your health care and other service related to your healthcare. An example of a disclosure related to treatment would be when I consult with another health care provider, such as your psychiatrist.
- Health Care Operations are activates that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement, business-related matters such as audits and administrative services, and case management and care coordination.
- Business Associates: My co-workers have no access to my records. "Use" applies only to within my office, such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.
- "Disclosure" applies to outside of my office, such as releasing, transferring or providing access to information about you to other parties.
- "Consent" is a general permission that allows me to use and disclose your health care information for routine purposes of treatment, payment and operations. For example, under the law, you must sign this consent form before I can begin to see you for treatment or provide other health services.
- “Authorization” is required by law and involves your written permission to use and disclose information not covered by the consent form. There are a few cases (see above) in which I am allowed, even required to use and disclose your information without your consent or authorization. I will keep a record of disclosures, and this will be available to you.
IV. Patient’s Rights and Provider’s Duties:
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information that I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make you request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
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 seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of neither PHI for which you have neither provided or consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process.
Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If your request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain notes or to information compiled in reasonable anticipation or, or use in, a civil criminal, or administrative proceeding.
Right to Amend: If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; and 4) is accurate and complete.
Right to a copy of this notice: You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time.
Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
Acknowledgement of Receipt of Notice of Privacy Practices
Please print, sign your name and date below. I have been provided a copy of the privacy practices that will apply to services provided by Dr.
Michele D. Goss.
I consent to these policies as a condition of receiving services.