HIPAA Privacy Statement

Notice of Therapist’s 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

I may use or disclose your protected health information (PHI), for treatment, payment, and healthcare 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”

o Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

o Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

o 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, business- related matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside my practice, such as releasing, transferring or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. And “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operation, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

Notice 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) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

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

• Child Abuse‐ If I have reasonable cause to believe that a child has been abused, I must report that suspicion to the appropriate authority.

• Adult and Domestic Abuse‐ If I have reasonable cause to believe that an adult with a disability or elder person has had a physical injury or injuries inflicted upon such adult with a disability or elder person, other than by accidental means, or has been neglected or exploited , I must report that belief to the appropriate authority.

• Health Oversight Activities‐ If I am the subject of an inquiry by the Georgia Board of Psychological Examiners, I may be required to disclose protected health information regarding you in proceedings before the Board. • Judicial and Administrative Proceedings‐ If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. I will first assert legal privilege to deny access to your PHI. 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 I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you or the intended victim.

• Worker’s Compensation‐ I 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

Patient’s Rights:

• Right to Request Restrictions‐ You have the right to request restrictions on certain uses and disclosures of protected health information. I will whenever possible work with your request, however, I am not required to comply with your 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, I 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. Under certain unusual circumstances I may deny such a request, but in some cases you may have this decision reviewed. If this is the case, I 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. Whenever possible, I will work with your request; however, in certain circumstances I may need to deny your request. I 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, I will discuss with you the details of the accounting process.

Therapist’s duties:

• I am 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.

• I may need to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

• If I revise my policies and procedures, I will notify you in person or by mail. V. Complaints If you are concerned that I have violated you privacy rights, or you disagree with a decision I made about access to your records please talk with me about this. You may contact me at (706)-363-5033. Contacting me regarding your complaint is an important first step in resolving it.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate contact information if you have difficulty finding it.

VI. Effective Date, restrictions, and Changes to Privacy Policy

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHIs that I maintain. I will provide you with a revised notice by mail or in person.