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Privacy
Policy
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Confidentiality l Exceptions to Confidentiality l Patient Rights l Privacy Document
Confidentiality: Information about your coming to therapy, and what you
share is private, and can not be released without your permission.
There are a few exceptions to confidentiality, that apply to all
Licensed Health Care Providers in the State of Massachusetts.
MASSACHUSETTS NOTICE FORM
Notice of Psychologists’ 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
I 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 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.
Payment 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.
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, and case management and care
coordination.
“Use”
applies only to activities within my office, such as sharing,
employing, applying, utilizing, examining, and analyzing information
that identifies you.
“Disclosure”
applies to activities outside of my office, such as releasing,
transferring, or providing access to information about you to other
parties.
II. Uses and Disclosures Requiring Authorization
I 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, I 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 I have
made about our conversation during a private, group, joint, or family
counseling session, which I have 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) 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.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse: If I, in my professional
capacity, have reasonable cause to believe that a minor child is
suffering physical or emotional injury resulting from abuse inflicted
upon him or her which causes harm or substantial risk of harm to the
child's health or welfare (including sexual abuse), or from neglect,
including malnutrition, I must immediately report such condition to the
Massachusetts Department of Social Services.
- Adult and Domestic Abuse: If I have reasonable
cause to believe that an elderly person (age 60 or older) is suffering
from or has died as a result of abuse, I must immediately make a report
to the Massachusetts Department of Elder Affairs.
- Health Oversight: The Board of Registration of
Psychologists has the power, when necessary, to subpoena relevant
records should I be the focus of an inquiry.
- Judicial or Administrative Proceedings: If you
are involved in a court proceeding 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 without written authorization from you or your
legally-appointed representative, 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
communicate to me an explicit threat to kill or inflict serious bodily
injury upon an identified person and you have the apparent intent and
ability to carry out the threat, I must take reasonable
precautions. Reasonable precautions may include warning the
potential victim, notifying law enforcement, or arranging for your
hospitalization. I must also do so if I know you have a history
of physical violence and I believe there is a clear and present danger
that you will attempt to kill or inflict bodily injury upon an
identified person. Furthermore, if you present a clear and
present danger to yourself and refuse to accept further appropriate
treatment, and I have a reasonable basis to believe that you can be
committed to a hospital, I must seek said commitment and may contact
members of your family or other individuals if it would assist in
protecting you.
- Worker’s Compensation: If you file a
workers’ compensation claim, your records relevant to that claim
will not be confidential to entities such as your employer, the insurer
and the Division of Worker’s Compensation.
IV. Patient's Rights and Psychologist'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 about you. However, I am 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
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 and psychotherapy
notes 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.
- Right 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.
- Right 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 electronically.
Psychologist’s Duties:
- I 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.
- I 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.
- If I revise my policies and procedures, I will mail you a copy of any revisions.
V. Complaints
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 to
discuss it.
You may also send a
written complaint to the Secretary of the U.S. Department of Health and
Human Services. The person listed above can provide you with the
appropriate address upon request.
VI. Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on 4/14/2003
I reserve the right to
change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain. I will provide you with a
revised notice by mail.
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