NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. PLEDGE REGARDING HEALTH INFORMATION: Center For Psychological Performance, Inc. understands that health information about you and/or your child(ren) is personal. We are committed to protecting health information about you and/or your child(ren). Center For Psychological Performance, Inc. creates a record of the care and services you and/or your child(ren) receive from them. Center For Psychological Performance, Inc. needs this record to provide you and/or your child(ren) with quality care and to comply with certain legal requirements. This notice applies to all of the records of care generated by this mental health care practice. This notice will tell you about the ways in which Center For Psychological Performance, Inc. may use and disclose health information about you and/or your child(ren). Center For Psychological Performance, Inc. also describes your rights to the health information they keep about you and/or your child(ren), and describes certain obligations they have regarding the use and disclosure of health information. Center For Psychological Performance, Inc. is required by law to:
Make sure that protected health information (“PHI”) that identifies you and/or your child(ren) is kept private.
Follow the terms of the notice that is currently in effect.
Center For Psychological Performance, Inc. can change the terms of this notice, and such changes will apply to all information they have about you and/or your child(ren). The new notice will be available upon request and located in Center For Psychological Performance, Inc. office.
II. HOW CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU AND/OR YOUR CHILD(REN):
The following categories describe different ways that Center For Psychological Performance, Inc. uses and discloses health information. For each category of uses or disclosures, Center For Psychological Performance, Inc. will explain what they mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Center For Psychological Performance, Inc. is permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. Center For Psychological Performance, Inc. may also disclose protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, the clinician would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, Center For Psychological Performance, Inc. may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful processes by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. Center For Psychological Performance, Inc. keeps “psychotherapy notes” for therapy sessions as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For our use in treating you and/or your child(ren).
b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For our use in defending herself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate her compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As psychotherapists, Center For Psychological Performance, Inc. will not use or disclose your PHI nor your child(ren)’s PHI for marketing purposes.
3. Sale of PHI. As psychotherapists, Center For Psychological Performance, Inc. will not sell your PHI nor your child(ren)’s PHI in the regular course of her business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, Center For Psychological Performance, Inc. can use and disclose your PHI or your child(ren)’s PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although her preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on her premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of clients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although her preference is to obtain an Authorization from you, Center For Psychological Performance, Inc. may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health-related benefits or services. Center For Psychological Performance, Inc. may use and disclose your PHI and/or your child(ren)’s PHI to contact you to remind you that you have an appointment with them. We may also use and disclose your PHI and/or your child(ren)’s PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1.Disclosures to family, friends, or others. Center For Psychological Performance, Inc. may provide your PHI and/or your child(ren)’s PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI AND/OR YOUR CHILD(REN)’S PHI:
1. The Right to Request Limits on Uses and Disclosures of Your and/or Your Child(ren)’s PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Center For Psychological Performance, Inc. is not required to agree to your request, and they may say “no” if they believes it would affect your or your child(ren)’s health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI and/or your child(ren)’s PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How to Send PHI to You. You have the right to ask Center For Psychological Performance, Inc. to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that Center For Psychological Performance, Inc. has about you. They will provide you with a copy of your or your child(ren)’s record, or a summary of it if you agree to receive a summary, within 30 days of receiving your written request, and they may charge a reasonable, cost-based fee for doing so.
5. The Right to Get a List of the Disclosures Center For Psychological Performance, Inc. Has Made. You have the right to request a list of instances in which Center For Psychological Performance, Inc. has disclosed your or your child(ren)’s PHI for purposes other than treatment, payment, or health care operations, or for which you provided her with an Authorization. They will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list they will give you will include disclosures made in the last six years unless you request a shorter time. Center For Psychological Performance, Inc. will provide the list to you at no charge, but if you make more than one request in the same year, they will charge you a reasonable cost-based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your or your child(ren)’s PHI, or that a piece of important information is missing from your or your child(ren)’s PHI, you have the right to request that Center For Psychological Performance, Inc. correct the existing information or add the missing information. Center For Psychological Performance, Inc. may say “no” to your request, but they will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 20, 2013
Acknowledgment of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your and/or your child(ren)’s protected health information. By your signature below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.