HIPPA 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.

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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 an 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, 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 I am asked for information for purposes outside of treatment, payment or 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 may 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, 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 have reasonable cause to know or suspect that a child has been subjected to abuse or neglect, I must immediately report this to the appropriate authorities. 
  • Adult and Domestic Abuse - If I have reasonable cause to believe that an at-risk adult has been mistreated, self-neglected, or financially exploited and is at imminent risk of mistreatment, self-neglect, or financial exploitation, then I must report this belief to the appropriate authorities.        
  • Health Oversight Activities - If the Colorado State Board of Psychologist Examiners or an authorized professional review committee is reviewing my services, I may disclose PHI to that board or committee.      
  • Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and I will not release information without your written authorization or a court order. The privilege does not apply when you are being evaluated or 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 a serious threat of imminent physical violence against a specific person or persons, I have a duty to notify any person or persons specifically threatened, as well as a duty to notify an appropriate law enforcement agency or by taking other appropriate action.  If I believe that you are at imminent risk of inflicting serious harm on yourself, I may disclose information necessary to protect you.  In either case, I may disclose information in order to initiate hospitalization.
  • Worker's Compensation - I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs, established by law, that provided benefits for work-related injuries or illness without regard to fault.        

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 regarding 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. On 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 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. 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 provide you with a revised notice either in person or by mail.   

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 the State Grievance Board, 1560 Broadway, Suite 1340, Denver, CO., 80202; phone: 303.894.7766. 

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 Date1 and Changes to Privacy Policy

This notice will go into effect on April 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 either in person or by mail. 

 

Acknowledgement of Receipt of Notice of Psychologists’ Policies and Practices to Protect the Privacy of Client’s Health Information