HIPPA Privacy Notice Form
This notice describes how psychological and medical information about you may be used and disclosed. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations De Santo Counseling may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your written authorization. Definitions: “PHI” refers to information in your health record that could identify you. “Treatment, Payment and Health Care Operations” ◦Treatment is the provision, coordination, or management of you health care and other services related to your health care. An example of treatment is my consulting with another health care provider, such as your family physician. ◦Payment is obtaining reimbursement for your health care. Examples of payment are when your PHI is disclosed 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 quality assessment and improvement activities, business related matters such as audits and administrative services, as well as case management and care coordination. “Use” applies only to activities within the practice such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you. “Disclosure” applies to activities outside of the practice such as releasing, transferring, or providing access to information about you to other parties. “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a legally required form. II. Other Uses and Disclosures Requiring Authorization De Santo Counseling may disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when Inner Balance Psychotherapy Services, Ltd is asked for information outside of treatment, payment, or health care operations, an authorization will be obtained from you prior to releasing the information. You may revoke all such authorizations of PHI at any time, provided such revocation is in writing. You may not revoke an authorization to the extent that 1.) De Santo Counseling has relied on that authorization, or 2.) If the authorization was obtained as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures Without Authorization De Santo Counseling may use or disclose PHI without your consent or authorization in the following circumstances: ◦ Child Abuse- If I have reasonable cause to believe a child known to me in my professional capacity may be an abused or a neglected child, I must report this belief to the appropriate authorities. ◦ Adult and Domestic Abuse- If I have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, I must report this belief to the appropriate authorities. ◦ Health Oversight Activities- I may disclose PHI regarding you to a health oversight agency for oversight activities authorized by law, including licensure and disciplinary actions. ◦ Judicial and Administrative Proceedings- If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis, and treatment, and the records thereof, such information is privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated by a third party or when the evaluation is court ordered. You must be informed in advance if this is the case. ◦ 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 a clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures believed to be 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 considered necessary to protect you from harm. ◦ Worker’s Compensation- I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with the laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault. IV. Patient’s Rights and Psychotherapist’s Duties Patient’s rights: ◦ Right to Request Restrictions- You have the right to request restrictions on certain uses and disclosures of PHI. However, I am 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 communication of PHI by alternative means and at alternative locations. ◦ Right to Inspect and Copy- You have the right to inspect or obtain a copy of PHI in my mental health and billing records used to make decisions about you as long as the PHI is maintained in the record. The details of the access process will be discussed at your request. ◦ Right to Amend- You have the right to request an amendment of PHI as long as the PHI is maintained in the record. I may be deny your request. The details of the amendment process will be discussed on your request. ◦ Right to an accounting- You generally have the right to receive an accounting of disclosures of PHI. The details of the accounting process will be discussed at your request. ◦ Right to a Paper Copy- You have the right to receive a copy of the notice upon request even if you have agreed to receive the notice electronically. Psychotherapist’s Duties: ◦ To maintain the privacy of PHI and to provide a notice of my legal duties and privacy practice with respect to PHI. ◦ To reserve the right to change my privacy policies and practices described in this notice. Unless you are notified of such changes, it is required that I abide by the terms currently in effect. ◦ If I revise my policies and procedures, you will be notified in person or by mail. V. Complaints If you are concerned that I have violated your privacy rights or you disagree with a decision I made about access to your records, please contact me at (773) 244-9620. You may also contact the Illinois Department of Insurance Consumer Assistance Hotline at (888) 445-5364 or their Consumer Services Section at (312) 814-2427. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. VI. Effective Date, Restrictions and Changes to Privacy Policy This notice is effective Novemeber 2, 2007. I reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice in writing.
I have read and understood the above information as shown by my signature above.