Notice of My 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
II. Uses and Disclosures Requiring Authorizations
III. Uses and Disclosures with Neither Consent nor Authorization
IV. Patients' Rights and Psychologists' Duties
VI. Effective Date
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:
refers to information in your health record that could identify you.
Payment and Health Care Operations”
is when I provide,
coordinate, or manage your health care and other services related to
your health care. An example of treatment would be when I
consult with another health care provider, such as your family
physician or another psychologist.
is when I obtain
reimbursement for your healthcare. Examples
of payment are when I disclose
your PHI to your health insurer to obtain reimbursement for your health
care or to determine eligibility or coverage.
Care Operations are activities that relate to the performance and
operation of my 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.
applies only to activities within my [office, clinic, practice group, etc.]
such as sharing, employing, applying, utilizing, examining, and analyzing
information that identifies you.
applies to activities outside of my [office, clinic, practice group, etc.],
such as releasing, transferring, or providing access to information about
you to other parties.
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 I am asked for information for purposes outside of treatment,
payment and health care operations, he will obtain an authorization from you
before releasing this information
You may revoke all
such authorizations at any time, provided each revocation is in writing. You may
not revoke an authorization to the extent that (1) I have 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.
I may use or
disclose PHI without your consent or authorization in the following
Abuse: If I have reasonable cause, on the basis of my professional
judgment, to suspect abuse of children with whom he comes into contact in my
professional capacity, I am required by law to report this to the
Pennsylvania Department of Public Welfare.
Adult and Domestic Abuse: If I have reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), I may report such to the local agency which provides protective services.
or Administrative Proceedings: If you are involved in a court proceeding
and a request is made about the professional services I provided you or the
records thereof, such information is privileged under state law, and I will
not release the information without your written consent, 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 you express a serious threat, or intent to kill or seriously injure an identified or readily identifiable person or group of people, and I determine that you are likely to carry out the threat, I must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
Compensation: If you file a worker’s compensation claim, I will be
required to file periodic reports with your employer which shall include,
where pertinent, history, diagnosis, treatment, and prognosis.
to Request Restrictions –
You have the right to request restrictions on certain uses and
disclosures of protected health information about you. However, I am not
required to agree to a restriction you request.
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.)
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, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial 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. I may deny your request. On your request, I will discuss with you the details of the amendment process.
to an Accounting – You generally have the right to receive an
accounting of disclosures of PHI for which you have neither provided consent
nor authorization (as described in Section III of this Notice).
On your request, I will
discuss with you the details of the accounting process.
to a Paper Copy – You have the right to obtain a paper copy of the
notice from me upon request, even if you have agreed to receive the notice
am required by law to maintain the privacy of PHI and to provide you
with a notice of my legal duties and privacy practices with respect to PHI.
reserve the right to change the privacy policies and practices
described in this notice. Unless I notify
you of such changes, however, I am
required to abide by the terms currently in effect.
I revise my policies and
procedures, I will notify you in
writing at your address of record.
If you are concerned
that I have violated your privacy
rights, or you disagree with a decision I made
about access to your records, you may contact me directly at WCPA.
You may also send a
written complaint to the Secretary of the U.S. Department of Health and Human
Services. I can provide you with the
appropriate address upon request.
This notice will go
into effect on
Copyright© 2003-2010 Dr. Jeffrey Bryer