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.

We may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your permission.  To help clarify thee 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 we provide, coordinate or manage your health care and other services related to your health care.  An example of treatment would be when your therapist consults with another health care provider such as your family physician or another therapist.

▪ Payment is when we obtain reimbursement for your health care.  Examples of payments are when we disclose your PHI to your health insurer to obtain reimbursement or to determine eligibility or coverage.

▪ Health Care Operations are activities that relate to the performance and operation of our 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 Southpark Psychology, Ltd., such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.

● "Disclosure" applies to activities outside of Southpark Psychology, Ltd., 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.

We may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse - If we have reasonable cause to believe a child know to us in our professional capacity may be an abused child or a 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, such as an elderly person) has been abused, neglected or is 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 your permission 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 must be informed in advance if this is the case.

Serious Threat to Health or Safety - If you communicate to us 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.

Worker's Compensation - 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.

Patient's Rights:

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information.  However, we are 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 us.  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 mental health and billing records used tomake 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.  We may deny your request.  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 the details of the accounting process.

Right to a Paper Copy - You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive the notice electronically.

Therapist's Duties:

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice at any time.  Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

If we revise our policies and procedures, we will change the privacy notice available in our website at www.SouthparkPsychology.com and will provide all patients then current with a revised notice.

This notice will go info effect November 1, 2004.