Sarah Anne Edwards, PhD, LCSW5769
2624 Teakwood Court, P.O. Box 6775 661 242-2624 phone 661 242-1692 fax firstname.lastname@example.org
THIS NOTICE OF PRIVATE PRACTICES POLICIES DESCRIBES HOW HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have been to a medical doctor or other health care provider you have undoubtedly seen and signed a HIPPA form like this one. HIPPA is a federal law designed to protect the confidentiality of health records about you, your past, present or future physical or mental health and the treatment you receive. This information is referred to as Protected Health Information (“PHI”).
Keeping strict confidentiality of your PHI is extremely important to me. I and my office are HIPPA compliant and we make every effort to insure confidentiality of your records. This form tells you specifically how HIPPA protects confidentiality as well as its limits. It also describes your rights regarding how you may gain access to and control your PHI.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
Generally all PHI can only be shared with your verbal or written authorization. There are seven circumstances, however, when I as a Licensed Clinical Social Worker in the state of California and member of the National Association of Social Workers must by law disclose PHI.
REQUIRED BY LAW
- For you. I must provide your PHI to you upon your request. In addition, I must make disclosures to the Secretary of
the Department of Health and Human Services to investigate or determine my compliance with HIPPA requirements.
- Child or Elder Abuse. I am what is called a “Mandated Reporter.” This means I must report incidents of abuse or neglect of minors or the elderly. This includes downloads, streams, or accessing of images of any person under the age of 18 engaged in an act of obscene sexual conduct.
- Danger to Self or Other. I must disclose information if necessary to prevent or lessen a serious and imminent threat to you, the public or another person. This does not apply to discussion of suicidal thoughts in your sessions.
- Medical Emergency. I may use or disclose your PHI to medical personnel when needed to prevent serious harm. We will provide you with a copy of what information was disclosed as soon as practical after resolution of the emergency.
- Public Health. I may use or disclose your PMI to authorized authorities for mandatory public health activities needed to prevent or control disease, injury or disability.
- For Payment. We may use and disclose PHI needed by your third party insurer so I can be paid for services provided to you, i.e. making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking their utilization review.
Should you not want required information to be provided to your insurer, you must let me know as you would be responsible to pay my fees for service yourself.
I may use or disclose limited PHI needed for my staff and biller to carry out necessary standard business activities such as filing, answering the phone, mailing materials, submitting claims, scheduling appointments, answering the door. To share even this limited PHI with them I must have a written contract requiring them to safeguard your privacy. These contracts are signed and on file. As a private practitioner I do not have supervisors, administrators or co-workers to share clinical information with. When needed I consult during bi-weekly peer counseling with two respected colleagues but at no time is any identifying PHI is ever disclosed.
In all the cases above I will disclose only the minimum amount of PHI necessary to meet these requirements. The notes you see me during in sessions that may include sensitive PHI you share with me are my property and for my eyes only. They
are specifically excluded under HIPPA and therefore cannot be required to be shown to anyone for any reason. I take them only for the purpose of helping me recall various aspects of the work we have done together.
With Your Authorization
With your documented consent there are times I can share your PHI. Often there may be circumstances where you ask me to share such information. At other times I might suggest it would be beneficial for me to share certain PHI information. Sometimes other agencies that have served you will request your PHI. In all of these and the following cases I can only do so with your authorization.
- Other Processionals Involved in Your Care. With your consent I may share PHI with or request information from your PCP, other medical specialists, school professionals, your spiritual advisor, lawyer or other specified individuals when we deem it useful to your treatment goals.
- Family Involvement in Care. Based on your consent or as necessary to prevent serious harm, I may disclose information to close family members or friends you specify who are directly involved in your treatment.
- Judicial and Administrative Proceeding. With your consent I may disclose aspects of your PHI pursuant to a subpoena, court order, administrative order or similar process.
- Health Overseers. Based on your prior consent, if required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections of my practice.
- Law Enforcement. I may disclose select PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.\
- Specialized Government Requests. On your written consent I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on mandatory disclosure laws and the need to prevent serious harm.
- Upon Your Death. Based on your prior consent I may disclose PHI after your death as mandated by state law, or to a family member or friends who were involved in your care or payment for care prior to death. A release of information regarding your death may be limited to an executor or administrator of your estate or the person identified as next-of-kin. PHI of persons who have been deceased for more than fifty (50) years is not protected under HIPAA.
HIPPA covers several other circumstances when PHI can be shared upon consent but I do not and will not carry out any of the following:
- Research. I do not do and will not use PHI for research purposes.
- I do not do fundraising and therefore will never use PHI for this purpose.
- I never use PHI for marketing purposes.
Any other uses and disclosures not specifically permitted by applicable law will be made only with your written authorization and may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your prior authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) disclosures that constitute a sale of PHI should I sell my practice; and (iii) other uses and disclosures not described in this Notice of Privacy Practices.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to me at PO Box 6775 Pine Mountain Club, CA 93222.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set,” that is a record set contains mental health/ medical and billing records and any other records used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in my personal psychotherapy notes. I may charge a reasonable, cost-based fee for copies. I do not maintain PHI electronically other than for billing purposes, which you can request. You may also request that a copy of your PHI be provided to another person.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you a provide you with a copy. Please contact me if you have any questions.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, I am required to honor your request for a restriction.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way. We will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
- Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. I will provide you with a copy of the revised Notice.
If you believe I have violated your privacy rights, you have the right to file a complaint in writing to Privacy Issue, P.O. Box 6775, Pine Mountain Club, CA. 93222 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. Please do speak with us first as I want to protect your privacy, will work to correct any such issues and will not retaliate against you for filing a complaint.