PENNSYLVANIA 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
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 healthcare, or coordinate or manage your health care and other services related to your health care. An example of coordinating treatment would be when I consult with another health care provider, such as your physician or another psychologist, or with a member of your family.
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 practice group 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.
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 have reasonable cause, on the basis of my professional judgment, to suspect abuse of children with whom I come into contact in my professional capacity, I am required by law to report this to the Pennsylvania Department of Public Welfare.
Adult and Domestic Abuse: If I have reasonable cause to believe that an elderly adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), I may report such to the local agency which provides protective services.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release the 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 you express a serious threat, or intent to kill or seriously injure yourself or an identified or readily identifiable person or group of people, and I determine that you are likely to carry out the threat, I must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of the threat or intent.
Worker's Compensation: If you file a worker's compensation claim and your employer referred you, I will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis.
IV. Patient's Rights and Therapist's Duties
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 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.
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 clients with a revised notice by mail.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me, Thomas Nowak, at 412-200-8171.
If you believe that your privacy rights have been violated and wish to file a complaint with me or my office, you may send your written complaint to me, Thomas Nowak, MA, CCC-5th Floor, 801 Union Place, Pittsburgh, PA 15212.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on 01 August 2010
Restrictions to this policy: None.
CLIENT RIGHTS AND RESPONSIBLITIES
The following information is important to be familiar with as you begin your counseling relationship with me. If you have additional questions or concerns, please discuss them with me.
I am trained and experienced in the behavioral sciences. I also respect and appreciate the value of religion and spirituality in a person’s life. Various modalities of counseling are available including individual, couples, family, and group therapy. A recommendation to consult with a psychiatrist for possible medication may be made to help alleviate symptoms that are difficult to change and particularly distressing to you.
While every counseling relationship is unique, I am dedicated to providing a secure and empathic relationship in which to explore, understand, and as far as possible, help resolve your difficulties and concerns. As a client you have the right to:
v Be treated with dignity and respect
v Participate in the planning of your counseling process and goals
v Understand clearly the nature and cost of the process
v Terminate your counseling at will
In case of emergency, I can be reached at any time of the day or night at: 412-200-8171. If I know that I will be unavailable due to sickness or vacation time, then you will have the number of a designated counselor to call if in crisis. You can also receive immediate assistance by going to your nearest hospital emergency room or calling the Allegheny County crisis network at 1-888-796-8226.
Communication between you and I is documented and kept in a confidential file. The confidentiality of the counseling relationship is carefully maintained. In general, and unless you sign a “Release of Information” form, the information in your file cannot be shared with anyone who is not directly involved in your treatment. In cases of couple or family counseling, all participants over the age of 18 must authorize this release. There is a reasonable copying charge for releasing information at your request.
All use, disclosure, and accessing of personal medical information is federally regulated by the Health Insurance Portability and Accountability Act (HIPAA). The packet of information you have received contains a “Notice of Privacy Practices,” which is a detailed summary of the provisions of this law. You are entitled to read it before signing any consent forms.
HIPPA does mandate some exceptions to absolute confidentiality. These include:
v The counselor’s right to use or disclose any medical information that is required for purposes of carrying out treatment and related health-care operations, and for obtaining payment for services.
v The requirement that counselors share with the proper authorities information regarding reports or actions of suicidal or homicidal intent; evidence of child abuse; and situations of life-threatening medical emergencies. In such instances my consent is not required.
Beyond those restrictions stipulated in HIPPA, you may request additional restrictions on the use and disclosure of your medical information. I will cooperate as far as possible, but am not required, to agree to such requests. Where there is agreement, however, it will be placed in writing.
Your therapy file is the property of your counselor; however, you have the right to review and discuss your file with your counselor, or to request a copy of it at a reasonable charge.
Completion or Termination of Counseling
By voluntarily agreeing to treatment, you also have the right to terminate services at any time, even if this is against professional advice. Generally, your counseling is considered completed when you have accomplished your goals for counseling, you need a temporary break, or you believe that continued counseling will be of no further help. In any case, please discuss this decision with your counselor in advance of your final session. This allows time to explore issues of maintaining gains, if a referral to other treatment is needed, and to explore issues relating to ending counseling and providing closure.
Keeping appointments is a essential part of the counseling process. Therefore, undue cancellations or missed appointments are grounds for discontinuing services. I will discuss with you me scheduling policy, and encourage you to discuss with me any anticipated scheduling problems. As noted in your fee agreement, nonpayment of fees also is grounds for termination, or temporary suspension, of services.
As an outpatient therapist, I am not equipped to deal effectively with certain types and levels of issues. These include detoxification from drugs or alcohol; persistent suicidal or homicidal impulses, intents or actions; or the need for daily, intensive, treatment. In these instances I am neither and effective nor a suitable resource for your concerns, and I will discuss with you the advisability or necessity of seeking help in a more appropriate setting.
As a client you are expected to refrain from any physical violence toward your counselor or anyone affiliated with the counseling site. Any such threat or act of violence is grounds for immediate termination of your relationship with your counselor.
Waiting Room Courtesy
It is important to be considerate of other client’s privacy and the need for as quiet and undisturbed a space as possible in the waiting area. Children may not be left unattended in the waiting room, unless they can supervise themselves and respect the needs and rights of other clients. There is no staff available to supervise children.
Feedback, Complaints, and Grievances
My ultimate goal is to enhance your health and well-being to the greatest extent possible, and to continually improve the quality and effectiveness of service. Toward this end your candid feedback, both positive and negative, is welcomed. Each counseling relationship is unique and unfolds in its own time and way. Occasionally, a client and counselor are unable to establish an effective level of rapport due to differences in style, personality, or values. If this is sensed by you in the current counseling relationship please discuss this with me to see if the differences can be resolved or if you would find it more helpful to see someone else.
Similarly, if you should have a complaint or grievance about your counseling please discuss this with me to gain clarification, and understanding, and to work toward a satisfactory resolution.