HIPAA Privacy Notice
Georgia Notice Form
Notice of 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
We 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:
· “PHI” refers to information in your health record that could identify you.
· “Treatment, Payment and Health Care Operations”: “Treatment” is when a therapist provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when we consult with anotherhealthcare provider such as your family physician or another therapist. “Payment” is when we obtain reimbursement for yourhealthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your healthcare or to determine eligibility or coverage. “Health 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, supervision of mental health practitioners to help them improve their counseling skills, and case management and care coordination.
· “Use” applies only to activities within my practice group, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my practice group, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or 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 we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes the therapist has made about your conversation during a private, group, joint, or family counseling session, which has been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse – If we have reasonable cause to believe that a child has been abused, we must report that belief to the appropriate authority.
· Adult and Domestic Abuse – If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, we must report that belief to the appropriate authority.
· Health Oversight Activities – If we are the subject of an inquiry by the Georgia Board of Professional Counselors, Social Workers and Marriage and Family Therapists, the Secretary of Health and Human Services, your insurance company, or are defendants to legal proceedings instituted by you, we may be required to disclose protected health information regarding you in those proceedings.
· Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services provided or the records thereof, such information is privileged under state law, and we will not release 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 we determine, or pursuant to the standards of our profession should determine, that you present a serious danger of violence to yourself or another, we may disclose information in order to provide protection against such danger for you or the intended victim.
· Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
· Law Enforcement- We may release medical information if asked to do so by a law enforcement official:
• In response to Court Order, subpoena, warrant, summons or similar process
• To identify or locate a subject, fugitive, material witness, or missing person
• About the victim of a crime, under certain limited circumstances, if we are unable to obtain the person’s agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at the Islands Counseling office or in the presence of a therapist working with Islands Counseling
• In emergency circumstances to report a crime; the location of the crime or victims, or the identify, description or location of the person who committed the crime.
IV. Patient’s Rights and Therapist’s Duties
Patient’s Rights:
· Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction 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 alternate means and at alternate locations. (For example, you may not want a family member to know that you are seeing a therapist. On your request, we 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we 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. We may deny your request. On your request, we will discuss with you the details of the amendment process.
· Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, your therapist will discuss with you the details of the accounting process.
· Right to a Paper Copy – You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.
Therapist’s Duties:
· We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
· Islands Counseling Services reserves the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
· If these policies and procedures are revised, Islands Counseling Services or The Haven at Islands Counseling Inc. will provide you with the revision at your next appointment.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact your treating therapist. If you believe that your privacy rights have been violated and wish to file a complaint with this office, you may send a written complaint via e-mail to kelli@islandscounseling.org. Or you may also file a complaint with the Secretary of Health and Human Services. You have specific rights under the Privacy Rule. Islands Counseling Services or The Haven at Islands Counseling Inc. and its associated therapists will not retaliate against you for exercising your right to file a complaint.