MARYLAND NOTICE FORM -- HIPAA, Privacy
Notice of Psychologist’s
Policies and Practices to Protect the Privacy of My Patient’s 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 may use or disclose your protected
health information (PHI), for treatment, payment, and health care
operations purposes with your written
authorization. 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, clinic, practice group, etc.] such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies you.
·
“Disclosure” applies to activities
outside of my [office, clinic, practice group, etc.], such as releasing,
transferring, or providing access to information about you to other parties.
·
“Authorization” is your written
permission to disclose confidential mental health information. All authorizations to disclose must be on a
specific legally required form.
I may
use or disclose PHI for purposes outside of treatment, payment, or health care
operations when your appropriate authorization is obtained. 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 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.
I may
use or disclose PHI without your consent or authorization in the following
circumstances:
·
Child
Abuse – If I
have reason to believe that a child has been subjected to abuse or neglect, I
must report this belief to the appropriate authorities.
·
Adult
and Domestic Abuse
– I may disclose protected health information regarding you if I reasonably
believe that you are a victim of abuse, neglect, self-neglector exploitation.
·
Health
Oversight Activities
– If I receive a subpoena from the Maryland Board of Examiners of Psychologists
because they are investigating my practice, I must disclose any PHI requested
by the Board.
·
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 specific threat of imminent harm against another
individual or if I believe that there is clear, imminent risk of physical or
mental injury being inflicted against another individual, I may make
disclosures that I believe are necessary to protect that individual from
harm. If I believe that you present an
imminent, serious risk of physical or mental injury or death to yourself, I may
make disclosures I consider necessary to protect you from harm.
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. 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. You have the right to inspect
or obtain a copy (or both) of
Psychotherapy Notes unless I believe the disclosure of the record will be
injurious to your health. On your
request, I will discuss with you the details of the request and denial process
for both PHI and Psychotherapy Notes.
·
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 written description of the
new policy to all current patients.
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 in writing to
express your concern. If you feel that I
do not adequately address or resolve your concern, you may contact the Maryland
Psychological Association at One Columbia Center, Suite 102, 10025 Governor
Warfield Parkway, Columbia, Maryland 21044.
You may
also send a written complaint to the Secretary of the U.S. Department of Health
and Human Services. The Maryland
Psychological Association, listed above, can be reached at 410-995-0499, and
can provide you with the appropriate address upon request.
This
notice will go into effect on April 14, 2003.
I
reserve the right to make changes to this agreement at any time based on my
professional judgment. I will provide
notice of such changes in writing to all current patients.
