VIRGINIA NOTICE FORM

Notice of Psychologists’ 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 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 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 psychologist.
  
  - Payment is when we help you to obtain reimbursement for your healthcare.
  Examples of payment are when we disclose your PHI to your health insurer to
  help you 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 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 our practice, such as sharing,
  employing, applying, utilizing, examining, and analyzing information that
  identifies you.
• “Disclosure” applies to activities outside of our practice, such as releasing,
  transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

We 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your psychologist has
made about your conversation during a private, group, joint, or family counseling session, which we 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) we 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

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

• Child Abuse: If we have reason to suspect that a child is abused or neglected, we are required by law to report the matter immediately to the Virginia Department of Social Services.
  
• Adult and Domestic Abuse: If we have reason to suspect that an adult is abused, neglected or exploited, we are required by law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.
  
• Health Oversight: The Virginia Board of Psychology has the power, when necessary, to subpoena relevant records should we be the focus of an inquiry.
  
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state
  law, and we will not release information without the written authorization of you or your legal representative, or a subpoena (of which you have been served, along with the proper notice required by state law). However, if you move to quash (block) the subpoena, we are required to place said records in a sealed envelope and provide them to the clerk of court of the appropriate jurisdiction so that the court can determine whether the records should be released. 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 your doctor is engaged in his/her professional duties and you communicate to him/her a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and your doctor believes you have the intent and ability to carry out that threat immediately or imminently, he/she must take steps to
  protect third parties. These precautions may include (1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18; or (2) notifying a law enforcement officer.
  
• Worker’s Compensation: If you file a worker's compensation claim, we are required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

IV. Patient's Rights and Psychologist's Duties

Patient’s Rights:

• Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of protected health information about you. 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 one of our doctors. Upon 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 of PHI and psychotherapy notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your doctor 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. We may deny your request. On your request, your doctor 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, your doctor 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 us upon request, even if you have agreed to receive the notice electronically.

Psychologist’s Duties:

• The doctor is required by law to maintain the privacy of PHI and to provide you with a notice of his/her legal duties and privacy practices with respect to PHI.
  
• The doctor reserves the right to make changes to this notice upon changes in the Privacy Rule Law. 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, an updated copy will be available in the office.

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact first your doctor, and secondarily our Director, Anita L. Auerbach, Ph.D.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Our office can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003.

We respect your privacy and the confidentiality of any personal information you discuss with us. In areas where your consent is not necessary, please be assured that we will nevertheless continue as always to make every effort possible not to share information about you without your knowledge.

In the event of procedural changes in our practice and/or any changes in the Privacy law, we reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. The newly updated form will be posted in the office waiting room and a copy will be provided to you upon request.