HIPAA NOTICE FORM

(Health Insurance Portability Accountability Act)

 

Policies and Practices to Protect the Privacy of Health Information:
Your protected health information (PHI) includes information that identifies you and tells about your past, present, or future physical or mental health or condition.

 

Requirement for Written Authorization
Unless otherwise provided for in this notice, I generally will obtain your written authorization before using your health information or sharing it with others.

 

Uses and Disclosures Not Requiring Your Written Authorization for Purposes of Treatment, Payment and Health Care Operations
There are circumstances in which I may use or disclose your protected health information (PHI), for treatment, payment and health care operations purposes without your written authorization. To help clarify these terms here are some definitions:

 

Treatment:	Refers to when I provide, coordinate, or manage your health care and services related to your health care. An example would be when I consult with another health care provider, such as your family physician or a psychiatrist.
Payment:	Refers to when I seek to obtain reimbursement for my services. An example would be when I disclose your PHI to your health Insurer to obtain reimbursement for your health care or to determine eligibility for coverage or to get authorization for care.
Health Care Operations:	Activities that relate to the performance and operation of my practice. Examples of health care operations are administrative services such as making appointments or leaving or receiving messages.
Use:	Applies to activities within my offices such as applying, utilizing, examining and analyzing information that identifies you.
Disclosure:	Applies to such activities as releasing, transferring or providing information about you to parties such as my billing service or insurance companies.

 

Use and Disclosure Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment or health care operations when your appropriate authorization is obtained. In those instances, when I am asked for confidential information about you, I will obtain an authorization from you before releasing this information. All authorizations to disclose must be on a form which I will furnish to you as needed. You may revoke authorizations at any time, provided each revocation is in writing, given to me in person or mailed to me at 4829 West Lane, Bethesda, MD 20814. You may not revoke an authorization to the extent that I have already relied on that authorization; or if the authorization was obtained as a condition of obtaining insurance coverage.

 

Uses and Disclosures without Authorization
The law allows and requires me to use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse:	If I have reason to believe that a child has been abused or neglected, I am legally required to report this belief to the appropriate authorities.
Adult and Domestic Abuse:	I will under certain circumstances disclose protected health information regarding you if I reasonably believe that you are a victim of abuse, neglect, self-neglect, or exploitation.
Serious Threat to Health or Safety:	If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm. If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.
Judicial and Administrative Proceedings:	If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, I will not release this information without your written authorization 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.
Health Oversight Activities:	If I receive a subpoena from the Maryland Board of Examiners because of an investigation, I must disclose any PHI requested by the Board.

 

Patient’s Rights and Psychotherapists Duties

Right to Request Restrictions:	You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.
Right to Request Confidential Communication 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. On your written request, I 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 my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances. The current cost to you for copying is $5.00 per page copied.
Right to Amend:	You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request.

 

Concerns or Complaints
If you are concerned that your privacy rights have been violated, or if you disagree with a decision made about access to your records, you may mail a written complaint to me at 4829 West Lane, Bethesda, MD 20814. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the appropriate address upon request.

 

Effective Date, Restrictions and Changes to Privacy Policy
The notice went into effect April 14, 2009. I reserve the right to change the terms of this notice and to make the new notice of provisions effective for all PHI that I maintain. I will provide you with a revised notice if this should occur.