NOTICE OF PRIVACY POLICY
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.
I understand that your privacy is important and I believe that HIPPA provides clients with a clear understanding of their rights and offers practical steps to protect your privacy thus I choose to offer HIPPA compliant guidelines for all clients. I will handle your health information only as allowed by Federal/State laws and adhering to the most stringent law that protects your health information. Protected health information (PHI) is information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services provided to you; or the payment for such health care. This Notice explains when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice. PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside of my practice. With some exceptions, I may not use or disclose more of your PHI than necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.
If at any time you believe your privacy rights have been violated, you may make a complaint. Names, addresses and phone numbers are available at the end of this notice. You will not suffer any change in services or retaliation for filing a complaint, cooperating in an investigation, or refusing to agree to something that you believe to be unlawful.
I. Confidentiality: Uses and Disclosures of Information Requiring Your Authorization or Consent
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship, or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.
II. “Limits of Confidentiality:” Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in this office/agency], and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and consent to accept my policies about confidentiality and its limits. We will discuss these issues now, but you may revisit the conversation at any time during our work together. I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or legally requirement:
· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Virginia law to report the matter immediately to the Virginia Department of Welfare or Social Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
· Health Oversight: By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make a report to the licensing board. If you are yourself a health care provider, I am required by law to report to your licensing board if I believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records for investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so that you (or your attorney, or I) can file a motion to quash (block) the subpoena and can give reasons why I think your records should be protected from disclosure. However, while awaiting the judge’s decision, I may be required to place said records in a sealed envelope and provide them to the Clerk of Court. In Virginia, parents’ records may not be used as evidence (i.e. are privileged) in child custody cases), including records about parents held by a child’s therapist; but a child’s records do not have that same protection.
NOTE: In civil court cases, therapy information or records are not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation 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: Under Virginia law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect that third party. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
· Records of Minors: Virginia has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if deemed necessary in the course of treatment.
Other uses and disclosures of information not covered by this Notice or by the laws that apply to me will be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of PHI about you. You also have the right to request a limit on the medical information that I disclose (or to whom you request a disclosure) about you to someone who is involved in your care or the payment for your care. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply. However, I am not required to agree to a restriction that you request.
· Right 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. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing and specify how or where you wish to be contacted.
· Right to an Accounting of Disclosures – 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 written request, I will discuss with you the details of the accounting process.
. Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing and incur a service charge for costs of copying and mailing the record. I may deny your request to inspect and make a copy in some circumstances, especially if certain psychotherapy notes or information compiled is in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding.
· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; however, I will add your request to the record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; and 4) is accurate and complete.
· Right to a Copy of this Notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. .
IV. Complaints: If you believe your privacy rights have been violated, you may discuss your concerns with me or file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
Commonwealth of Virginia
State Human Rights Regional Advocate
Northern Virginia Training Center
9901 Braddock Road
Fairfax, VA 22032
Phone: (703) 323-2098
V. Changes to Privacy Practices:
I reserve the right to change privacy policies and related practices at any time, as allowed by Federal and State laws and to make the change effective for all health information that we maintain and gather in the future. The Revised Privacy Notice will be available upon request, will contain the effective date and will be posted in the waiting room. Copies of the current notice will be available on request.