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
We 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 our health record that could identify you.
"Treatment, Payment, and Health Care Operations"
- Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another therapist.
- Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we 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, business0related matters such as audits and administrative services, and case management and care coordination.
"Use" applies only to activities within Southpark Psychology, Ltd., such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside Southpark Psychology, Ltd., such as releasing, transferring or providing access to information about you to other parties.
is your written permission to disclose confidential
mental health information. All authorizations to
disclose must be on a specific legally required
II. Other Uses and Disclosures Requiring Authorization
We 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.
You may revoke all such authorizations of PHI at any
time, provide each revocation is in writing. You
may not revoke an authorization to the extent that
(1) we have relied on that authorization; or (2) if
the authorization was obtained as a condition of
obtaining insu-rance coverage, law provides the
insurer the right to contest the claim under the
III. Uses and Disclosures without Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse - If I have reasonable cause to believe a child known to me in my professional capacity may be an abused child or neglected child, we must report this belief to the appropriate authorities.
Adult and Domestic Abuse - If we have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, we must report this belief to the appropriate authorities.
Health Oversight Activities - We may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.
Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and we must not release such information without a court order. We can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third party of where the evaluation is court ordered. You must 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 we believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.
- We may disclose protected health information
regarding you as authorized by and to the extent
necessary to comply with laws relating to worker's
compensation or other similar programs, established
by law, that provide benefits for work-related
injuries or illness without regard to fault.
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. However, we 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, we 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. On your request, we will discuss with you the details of the request for access 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. On your request, we 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, we 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.
? We are 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.
? We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
revise my policies and procedures, I will change the
privacy notice available in our website,
and will provide all patients then current with a
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 your therapist or the privacy officer at (309)797-2900.
If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to Privacy Officer, Southpark Psychology, 2100 52nd Avenue, Moline, Illinois 61265.
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.
You have specific rights under the Privacy Rule. We
will not retaliate against you for exercising your
right to file a complaint.