Notice of Privacy Practices

LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your (or your child’s) treatment to others if you sign a written Authorization form. However, authorization is not required in situations in which I am legally obligated to act:  If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused or neglected child, Illinois law requires that I file a report with the office of the Department of Children and Family Services.  If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, Illinois law requires that I file a report with the agency designated to receive such reports by the Department of Aging.  If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking hospitalization.  If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to discuss it with you before taking any action, as appropriate, and I will limit my disclosure to what is necessary. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. Rev. May 15, 2012 Page 5 2. NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. MY COMMITMENT TO YOUR PRIVACY My practice is dedicated to maintaining the privacy of your personal health information (PHI) as part of providing professional care. I am also required by law to keep your information private. These laws are complicated, but I must give you this information. A copy of this document is also available upon request. Please contact me about any questions or problems you may have. For treatment I use your medical information to provide you with psychological treatment services. These might include individual, family, or group therapy, psychological testing, treatment planning, or measuring the benefits of my services. I may share or disclose your PHI to others who provide treatment to you. For example, I am likely to share your information with your personal physician if you provide consent. If a team is treating you, they can share some of your PHI with me so that the services you receive will be able to work together. If you receive treatment in the future from other professionals, I can also share your PHI with them with your permission. For payment I may use your information to bill you or others so I can be paid for the treatments I provide to you. Your health care operations There are a few ways I may use or disclose your PHI for what are called health care operations. For example, I may use your PHI to see where I can make improvements in the care and services I provide. Other uses in health care Appointment reminders. I may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want me to call or write to you only at your home or your work or prefer some other way to reach you, I usually can arrange that. Just tell me. Treatment alternatives. I may use and disclose your PHI to tell you about or recommend possible treatment or alternatives that may be of help to you. Other benefits and services. I may use your PHI to tell you about health-related benefits or services that may be of interest to you. Business associates. There are some jobs that I may hire other businesses to do for me. In the law, they are called business associates. Examples include a telephone answering service, software vendors and a bill collection agency. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they will agree in their contract with me to safeguard your information. Page 6 USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION If I want to use your information for any purpose beside those described above, I need your permission on an Authorization form. I don’t expect to need this often. If you do authorize me to disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time I will not use or disclose your information for the purposes that we agreed to. Of course, I cannot take back any information I have disclosed with your permission or that we had used in our office. Of course, I will keep your health information private, but there are some times when the law requires me to use or share it. For example: 1. When there is a serious threat to your health and safety or the health and safety of another individual or the public. I will only share information with a person or organization that is able to help prevent or reduce the threat. 2. Some lawsuits and legal or court proceedings. 3. If a law enforcement official requires me to do so. 4. For workers Compensation and similar benefit programs. 5. When I receive information about abuse or neglect of a child, disabled adult, or person over age 60. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home and not at work, to schedule or cancel an appointment. I will try my best to do as you ask. 2. You have the right to ask me to limit what I tell people involved in your care or the payment for your care, such as family members, and friends. While I don’t necessarily have to agree to your request, if I do agree, I will keep our agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you. 3. You have the right to look at health information I have about you, such as your medical or billing records. You can even get a copy of these records, but I may charge you. 4. If you believe the information in your records is incorrect or missing important information¸ you can ask me to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to me. You must tell me the reasons you want to make changes. 5. Upon written request, you may obtain an accounting of certain disclosures of PHI made by me during any period of time prior to the date of your request provided such period does not exceed six years. 6. You have a right to a copy of this notice. If I change this NPP, I will provide you with a revised copy. 7. If you need more information or have questions about the privacy practices described above, please contact me. If you have a problem with how your PHI has been handled or if you believe your privacy right have been violated, contact me as well. You have the right to file a complaint with me and the Secretary of the Federal Department of Health and Human Services. I promise that I will not in any way limit your care here or take any actions against you if you complain.
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