Download File - Western Ohio Psychological Services, LLC

WESTERN OHIO PSYCHOLOGICAL SERVICES LLC
Notice of Privacy Practices
1. Uses and Disclosures for Treatment, Payment, and Health Care Options
Western Ohio Psychological Services LLC (WOPS LLC) may use or disclose your protected
health information (PHI) for treatment, payment, and health care purpose in most instances
without your consent under HIPPA (Privacy Act 1974), but we will obtain your written
consent prior to disclosing information outside of the practice, except as otherwise outlined
in this Policy. In every instance, we will only disclose the minimum necessary information in
order to accomplish the intended purpose.
 Definitions:
o PHI refers to any information that could identify you
o Use applies to activities within WOPS LLC
o Disclosure applies to activities outside of WOPS LLC, such as releasing or
providing access to information about you to other parties.
2. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, and health care
purposes when your written authorization is obtained. In the event that we are asked for
information for purposes outside of treatment, payment and health care purposes, we will
obtain an authorization from you before releasing this information. Examples of disclosures
requiring an authorization include disclosures to your partner, your spouse your children, and
your legal counsel. Any disclosure involving psychotherapy notes will require your signed
authorization, unless we are otherwise allowed or required by law to release them.
3. Uses and Disclosures Requiring Neither Consent Nor Authorization
We may use PHI without your consent or authorization as allowed by law, including under
the following circumstances:
a. Serious threat to health or safety: If we believe that you pose a clear and imminent
risk or harm or danger to yourself or another person, we may disclose relevant
confidential information to public authorities, the potential victim, other
professionals, and/or your family in order to protect against serious harm. If we
believe that there is the risk of imminent and serious physical harm we make take any
of the following actions: hospitalize you on an emergency basis, establish a treatment
plan to eliminate the potential for carrying out the threat or behavior, and/or
communicate with a law enforcement agency the nature of the threat and information
regarding the potential victim.
b. Worker’s Compensation: If you file a worker’s compensation claim, we may be
required to give your mental health information to relevant parties and officials.
c. Felony Reporting: We may be required by law to report any felony that you report to
use that has been or is being committed.
d. For Health Oversight Activities: If a government agency is requesting the
information for health oversight activities, such as audits, investigations, or licensure
and disciplinary activities.
PRIVACY ACT NOTICE
1
WESTERN OHIO PSYCHOLOGICAL SERVICES LLC
e. For Specific Government Functions: We may disclose PHI or military personnel
and veterans in certain situations, to correctional facilities in certain situations, and
for national security reasons, such as for the protection of the President
f. For Lawsuits and Other Legal Proceedings: If you are involved in a court
proceeding and a request is made for information concerning your information,
diagnosis, or treatment, such information is protected by law. If you are involved in
litigation, you should consult with your attorney to determine whether a court would
likely order us to disclose information. If a client files a complaint or lawsuit against
us, we may disclose relevant information regarding that client in order to defend
ourselves.
g. Abuse, Neglect, and Domestic Violence: If we know or have reason to suspect that a
child under 18 years of age or an intellectually or developmentally disabled person
has suffered or is suffering any physical or mental wound, injury, or disability, or
condition of a nature that reasonable indicates abuse or neglect, the law REQUIRES
that we file a report with the appropriate government agency. Once the report is filed,
we may be required to provide additional information. If we know or have reason to
believe that an adult client is the victim of domestic violence, we must note that in the
client’s record.
h. To Coroners and Medical Examiners: We may disclose PHI to coroners and
medical examiners to assist in the identification of a deceased person and to
determine cause of death
i. For Law Enforcement: We may release PHI and health information if asked to do so
by a law enforcement official in response to a court order, subpoena, warrant,
summons, or similar process, subject to all applicable legal requirements.
j. Required by Law: We will disclose PHI and health information when required to do
so by federal, state, or local law,
k. Public Health Risk: We may disclose health information in order to prevent or
control disease, injury, or disability; or report births, deaths, non-accidental physical
injuries, reactions to medications or problems with products
l. Information not Personally Identifiable: We may use or disclose information about
you in a way that does not personally identify you or reveal who you are.
4. Patient’s Rights and Our Responsibilities
Patient Rights
a. Right to Request Restrictions and Disclosures: You have the right to request to
restrict use and disclosure of PHI, however, we are not required to agree to certain
restrictions, except those legally required. We may not refuse your request to restrict
information from your insurance company should you elect the self-pay option and
you comply with the terms of self-pay.
b. Right to Receive Confidential Communications by Alternative Means: If your
request is reasonable, we will make every attempt to honor it.
c. Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of
PHI in our mental health records, except in some limited circumstances. This does not
apply to information created for use in a civil, criminal, or administrative action or
PRIVACY ACT NOTICE
2
WESTERN OHIO PSYCHOLOGICAL SERVICES LLC
proceeding. We may charge you reasonable rates for copies, mailing, and associated
fees and supplies. We may deny your request in some limited circumstances. Reasons
for the denial will be discussed with you.
d. 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, but will not the
request in the record. Reasons for the denial will be discussed with you.
e. Right to an Accounting: You have the right to receive an accounting of disclosures
made regarding your PHI, with some exceptions. Exceptions include, but are not
limited to: payment or other healthcare operations, an accounting involving records
on disclosures for treatment.
f. Right to a Paper Copy: You have a right to obtain a paper copy of the notice from
us upon request.
Our Responsibilities:
a. Privacy: We are required by law to maintain the privacy of PHI, to provide you with
this notice of our legal duties and privacy practices with respect to PHI, and to abide
by the terms of this notice.
b. Policy Change/Revision: We reserve the right to change or revise the privacy policy
and practices detailed in this notice and to make you aware of those changes and/or
revisions in writing.
c. Notification of Breach: In the event that we learn of a breach in our privacy
(electronic or paper information) related to your PHI, we will notify of this breach
and actions being taken to remedy the situation.
5. Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a
decision we have made about access to your records, you may file a complaint with us. In the
event that you are not satisfied with our response to your complaint, or you do not want to
file a complaint directly with us, you may send a written complaint to the Secretary of the
Unites States Department of Health and Human Services in Washington, D.C.
6. Effective Date
This notice is effective as of April 19, 2016
I, _____________________________________________ (print your name) hereby
acknowledge that I have received the Notice of Privacy Practices from Western Ohio
Psychological Services LLC.
Signature: _______________________________________
Date: _______________
Western Ohio Psychological Services LLC Staff Signature: _______________________
PRIVACY ACT NOTICE
3