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HIPAA Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully:
Patient Rights To Privacy:
I am dedicated to maintaining the privacy of your personal health information as part of providing professional care. In addition, I am required by law to keep your information private. These laws are complicated, but I must give you the legal information. This document is a shorter version of the full, legally required Notice of Privacy Practices. You may have a copy of the longer version, if you request it. Or, you may read the full version of the Notice of Privacy Practices on pages 89-96 (entitled HIPAA Help). If you have any questions or concerns about your rights or privacy, please speak to me about them. (In the HIPAA Help information folder, my role of discussing this information with you is called "privacy officer." Since I am a solo practitioner in my psychotherapy practice, I am also the "privacy officer.")
I will use the information about your health (obtained from you or from your other health care providers) mainly to provide you with treatment. I will also use it for business activities called healthcare operations in the HIPAA Help folder. This includes providing you with a receipt for session payments you have made and a diagnosis/diagnoses and type of treatment session provided, if requested. I will not be sending the billing statement to any insurance companies (unless you make a special request and sign an authorization form for me to do so). This gives you control over the distribution of your own healthcare information transmission to your insurer.
If you or I want to disclose (send/share/release) your healthcare information for any other purpose, I will discuss it with you and ask that you sign an authorization form to allow this. (I cannot disclose this information without your written permission.)
Exceptions to my legal/professional obligation to keep your healthcare information private:
When there is serious threat to your health/safety or to the health/safety of another individual/the public. (In this case, I would share information with person/organization who might be able to prevent/reduce these threats).
• Some lawsuits and/or legal court proceedings.
• If a law enforcement official requires me to do so.
• For Workers Compensation and similar benefit programs.
There are some other rare exception situations where I may disclose information without your permission: situations where your records might be needed to investigate a criminal; situations where your records are requested by public health officials for the investigation of diseases or injuries; situations after your death; situations where you are being investigated by the government or military officials. These exceptions are discussed in the long version of the Notice of Privacy Practices document on pages 89-96 in the green HIPAA Help folder on my waiting room shelf.
Your Rights Regarding Your Healthcare Information:
You can request that I communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask that I call you at home and not at work to schedule or cancel an appointment. I will do my best to do as you ask.
You have the right to limit what I tell people involved in your care (or people involved in paying for your care), such as family members and friends.
You have the right to look at the health information I have about you, such as your medical and billing records. You may even request a copy of these records, but I may charge you for administrative time ($60/hr, pro-rated) and copying ($.05/sheet). Please speak to me directly to make a request to look at your healthcare information. You are entitled to view the following information: the notations I make regarding the medication prescriptions and monitoring provided to you by another clinician, the modalities and frequencies of treatment sessions I have provided for you, the results of clinical tests/self-report forms/symptom monitoring sheets in your chart, a written summary (written by me) of your diagnosis, functional status, treatment plan, symptoms, prognosis and progress to date. The only exception to your automatic right to view information in your medical chart is the viewing of psychotherapy session notes that I write. There are specific laws governing psychotherapy session notes, because these notes are intended to assist the psychotherapist only, and have the potential for being misinterpreted by others. If you would still like to view the psychotherapy notes, please speak with me about this. I will review with you the pro's and con's of this, relevant to your treatment needs and situation.
You have the right to accurate information in your health records. If you believe my records contain incorrect or missing information, you have the right to ask me to make amendments to your records. Please make this request in writing, indicate the reasons you want to make these changes and give the written request to me for placement in your medical chart.
You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services (www.hhs.org). All complaints must be in writing. Filing a complaint will not change the healthcare I provide you.
You have the right to a copy of this notice. Please keep this copy. If I amend this Notice of Privacy Practices document, I will post changes in the waiting room area for your review, or you can request an amended copy.
If you have questions regarding this notice of my health information privacy policies, please speak to me directly. I can be reached by phone at (925) 377-0410, or by appointment in my office at 61 Moraga Way #6, Orinda CA.
Also, you may have other rights granted to you by the laws of the State of California and these may be the same or different than the federal rights I have described above. For further information on California State Law protecting patient rights, please visit www.chcf.org (the California Healthcare Foundation website). If you have additional questions about this issue, please ask me.
For further information on HIPAA regulations (Health Insurance Portability and Accountability Act, 1996), or your right to privacy regarding healthcare information, please visit www.hhs.gov/ocr/hipaa (the US Department of Health and Human Services website).
For further information about your rights as a psychotherapy patient, please visit www.apa.org/publicinfo/rights (the American Psychological Association's website).
A copy of the Standards for Privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164) of the OCR HIPAA Privacy Regulations (12-3-02, Rev. 4-3-03) is located in the green HIPAA Help folder on the shelf in my waiting room for your review.
61 Avenida de Orinda #100 Orinda, CA 94556 | (925) 377-0410 | email@example.com