NOTICE OF PRIVACY RIGHTS
THIS NOTICE DESCRIBES HOW MEDICAL
[INCLUDING MENTAL HEALTH] INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY. During the process of providing services to you,
the provider will obtain, record, and use mental health and medical
information about you that is protected health information.
Ordinarily, that information is confidential and will not be used or
disclosed, except as described below.
I. USES AND DISCLOSURES OF
PROTECTED INFORMATION
A. General Uses and Disclosures Not
Requiring the Client's Consent. The provider will use and disclose
protected health information in following ways.
1.
Treatment. Treatment refers
to the provision, coordination, or management of health care
[including mental health care] and related services by one or more
health care providers. For example, the provider will use your
information to plan your course of treatment. As to other examples,
the provider may consult with professional colleagues or ask
professional colleagues to cover calls or the practice for the
provider and will provide the information necessary to complete those
tasks.
2. Payment. Payment refers to the
activities undertaken by a health care provider [including a mental
health provider] to obtain or provide reimbursement for the provision
of health care. The provider will use your information to develop
accounts receivable information, bill you, and with your consent,
provide information to your insurance company or other third party
payer for services provided. The information provided to insurers and
other third party payers may include information that identifies you,
as well as your diagnosis, type of service, date of service, provider
name/identifier, and other information about your condition and
treatment. If you are covered by Medicaid, information will be
provided to the State of Colorado's Medicaid program, including but
not limited to your treatment, condition, diagnosis, and services
received.
3.
Health Care Operations.
Health Care Operations refers to activities undertaken by the provider
that are regular functions of management and administrative activities
of the practice. For example, the provider may use or disclose your
health information in the monitoring of service quality, staff
evaluation, and obtaining legal services.
4.
Contacting the Client. The
provider may contact you to remind you of appointments and to tell you
about treatments or other services that might be of benefit to you.
5. Required
by Law. The provider will
disclose protected health information when required by law or
necessary for health care oversight. This includes, but is not limited
to: (a) reporting child abuse or neglect; (b) when court ordered to
release information; (c) when there is a legal duty to warn or take
action regarding imminent danger to others; (d) when the client is a
danger to self or others or gravely disabled; (e) when a coroner is
investigating the client's death; or (f) to health oversight agencies
for oversight activities authorized by law and necessary for the
oversight of the health care system, government health care benefit
programs, or regulatory compliance.
6.
Crimes on the premises or observed by the provider.
Crimes that are observed by the
provider or the provider's staff, crimes that are directed toward the
provider or the provider's staff, or crimes that occur on the premises
will be reported to law enforcement.
7. Business
Associates. Some of the
functions of the provider may be provided by contracts with business
associates. For example, some of the billing, legal, auditing, and
practice management services may be provided by contracting with
outside entities to perform those services. In those situations,
protected health information will be provided to those contractors as
is needed to perform their contracted tasks. Business associates are
required to enter into an agreement maintaining the privacy of the
protected health information
released to them.
8.
Research.
The provider
may use or disclose protected health information for research purposes
if the relevant limitations of the Federal HIPAA Privacy Regulation
are followed. 45 CFR § 164.512(i).
9.
Involuntary Clients.
Information
regarding clients who are being treated involuntarily, pursuant to
law, will be shared with other treatment providers, legal entities,
third party payers and others, as necessary to provide the care and
management coordination needed.
10. Family
Members.
Except for
certain minors, incompetent clients, or involuntary clients, protected
health information cannot be provided to family members without the
client's consent. In situations where family members are present
during a discussion with the client, and it can be reasonably inferred
from the circumstances that the client does not object, information
may be disclosed in the course of that discussion. However, if the
client objects, protected health information will not be disclosed.
11.
Emergencies.
In life
threatening emergencies the provider will disclose information
necessary to avoid serious harm or death.
B. Client
Authorization or Release of Information. The provider may not use or
disclose protected health information in any other way without a
signed authorization or release of information. When you sign an
authorization, or a release of information, it may later be revoked,
provided that the revocation is in writing. The revocation will apply,
except to the extent the provider has already taken action in reliance
thereon.
II. YOUR RIGHTS
AS A CLIENT
A. Access to
Protected Health Information. You have the right to inspect and obtain
a copy of the protected health information the provider has regarding
you, in the designated record set. However, you do not have the right
to inspect or obtain a copy of psychotherapy notes. There are other
limitations to this right, which will be provided to you at the time
of your request, if any such limitation applies. To make a request,
ask your therapist.
B. Amendment of
Your Record. You have the right to request that the provider amend
your protected health information. The provider is not required to
amend the record if it is determined that the record is accurate and
complete. There are other exceptions, which will be provided to you at
the time of your request, if relevant, along with the appeal process
available to you. To make a request, ask your therapist.
C. Accounting
of Disclosures. You have the right to receive an accounting of certain
disclosures the provider has made regarding your protected health
information. However, that accounting does not include disclosures
that were made for the purpose of treatment, payment, or health care
operations. In addition, the accounting does not include disclosures
made to you, disclosures made pursuant to a signed Authorization, or
disclosures made prior to April 14, 2003. There are other exceptions
that will be provided to you, should you request an accounting. To
make a request, ask your therapist.
D.
Additional Restrictions. You have the right to request additional
restrictions on the use or disclosure of your health information. The
provider does not have to agree to that request, and there are certain
limits to any restriction, which will be provided to you at the time
of your request. To make a request, ask your therapist.
E. Alternative
Means of Receiving Confidential Communications. You have the right to
request that you receive communications of protected health
information from the provider by alternative means or at alternative
locations. For example, if you do not want the provider to mail bills
or other materials to your home, you can request that this information
be sent to another address. There are limitations to the granting of
such requests, which will be provided to you at the time of the
request process. To make a request, ask your therapist.
F. Copy of this
Notice. You have a right to obtain another copy of this Notice upon
request.
Copyright
2003Laurence B. James Not to be distributed outside of an authorized
organization and not to be used by any person or organization without
written permission from L.James.
III.
ADDITIONAL INFORMATION
A.
Privacy Laws. The provider is required by State and Federal law to
maintain the privacy of protected health information. In addition, the
provider is required by law to provide clients with notice of the
provider's legal duties and privacy practices with respect to
protected health information. That is the purpose of this Notice.
B. Terms of
the Notice and Changes to the Notice. The provider is required to
abide by the terms of this Notice, or any amended Notice that may
follow. The provider reserves the right to change the terms of its
Notice and to make the new Notice provisions effective for all
protected health information that it maintains. When the Notice is
revised, the revised Notice will be posted at the provider's service
delivery sites and will be available upon request.
C. Complaints
Regarding Privacy Rights. If you believe the provider has violated
your privacy rights, you have the right to complain to the provider.
Your therapist is the person designated within the practice to receive
your complaints. You also have the right to complain to the United
States Secretary of Health and Human Services by sending your
complaint to the Office of Civil Rights, U.S. Department of Health and
Human Services, 200 Independence Avenue, S.W., Room 515F, HHH Bldg.,
Washington, D.C. 20201. It is the policy of the provider that there
will be no retaliation for your filing of such complaints.
D. Additional
Information. If you desire additional information about your privacy
rights, ask your therapist.
Client's Signature
________________________________ Date ______________
Signature:
M.A., LMFT
Date: ____________
Notice is
effective August, 2014.
Phone number (719) 471-1225
[Written by
Frank Bennett, Ph.D. and Laurence James, Psy.D., JD.J
