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 Our providers 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 I provide,coordinate or manage your health care and other services related to your healthcare. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.
-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.
-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 practice group such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
·“Disclosure” applies to activities outside of my practice group 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, 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 I am asked for information for purposes outside of treatment, payment and health care operations, 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. 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, and the law provides the insurer the right 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 cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report of such within 48 hours to the Connecticut Department of Protective and Regulatory Services, the Connecticut Department of Child and Family, and/or to any local or state law enforcement agency. § Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of Protective and Regulatory Services. § Health Oversight: If a complaint is filed against one of my providers with the State Board governing their license, they have the authority to subpoena confidential mental health information from me relevant to that complaint. § Parents: If you are a parent of an unemancipated minor, and are acting as the minor’s personal representative, I may disclose protected health information to you under certain circumstances. An exception to this is if your child is legally authorized to consent to treatment (without separate consent from you), consents to such treatment, and does not request that you be treated as his or her personal representative. § 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 I will not release information, without written authorization from you or your personal or legally appointed representative, 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; in a judicial proceeding affecting the parent-child relationship; a judicial proceeding relating to a will if the client’s physical or mental condition is relevant to the execution of the will; or in any criminal proceeding as provided by law. § Serious Threat to Health or Safety: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to family members, medical or law enforcement personnel. § Military, National Security and Intelligence Activities, Protection of the President: I may disclose your protected health information for specialized government functions as authorized by law; determination of veteran’s benefits; requests as necessary by appropriate military commanding officers (if you are in the military); authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state; and the health, safety, and security of correctional institutions. § Food and Drug Administration: I may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order to report an adverse event or a defect related to a drug or medical device. § Research: I may disclose health information about you for research purposes in accordance with my legal obligations. I may disclose health information without a written authorization if an Institutional Review Board (IRB) has reviewed the research study and determined that the information is necessary for the research and will be adequately safeguarded. The information may be given to the FDA or other government agencies as part of applications to gain approval of new medications or to meet other reporting requirements such as reporting side effects. § Coroners, Medical Examiners, and Funeral Directors: I may release your health information to a coroner or medical examiner to identify a deceased or cause of death. Further, I may release your health information to a funeral director where such disclosure is necessary for the director to carry out his duties. § Required By Law:I may disclose protected health information about you as required by federal, state, or other applicable law.
§ Worker’s Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
IV. Patient's Rights and Provider’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, I am not required to agree to a restriction you request. · Right to ReceiveConfidential 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 my providers. Upon 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 a summary of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Connecticut law requires that requests for copies be made in writing and I ask that requests for inspection of your health record also be made in writing. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the requestand denial process. Please direct all written requests to :
Brian Eddy, M.D., LLC 1224 Farmington Avenue West Hartford, Connecticut 06107
Connecticut law requires that I provide copies or a summary or a written denial within 15 days of your request. I am allowed to charge a reasonable cost based fee per HIPAA Guidelines. · Right to Amend –You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. You must make your request in writing to me at my office.
I will respond within 60 days. I may deny your request if the information wasn’t created by this practice or the physicians here in this practice, if it is not part of the designated record set, is not available because of an appropriate denial, or if the information is accurate and complete. Even if I refuse to allow an amendment you are permitted to include a patient statement about the information at issue. On 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I 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 me upon request,even if you have agreed to receive the notice electronically.
· 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.
· To protect your privacy I will not discuss your personal or billing information in my front area. All phone calls regarding these issues will be forwarded to the appropriate individual.
· I reserve the right 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 promptly distribute the revised Notice, post it in the waiting area of my office, post it to my website, and make copies available to my patients and others.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may speak to me. A written complaint should be sent to: Brian Eddy, M.D., LLC 1224 Farmington Avenue West Hartford, Connecticut 06107
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services (HHS), Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201: or by calling (800) 368-1019; or by sending an email to OCRprivacy@hhs.gov. I cannot and will not, make you waive your rights to file a complaint as a condition of receiving care from me, or penalize you for filing a complaint.
VI. Psychotherapy Notes
In the course of your care with me, you may receive treatment from a mental health professional who keeps separate notes during the course of your therapy sessions about your conversations. These notes, known as “psychotherapy notes”, are kept apart from the rest of your medical record. They can contain details of your therapeutic conversation or especially sensitive material, as well as hunches or impressions about your therapy. Basic information such as your medication treatment record, counseling session start and stop times, the types and frequencies of treatment you receive, or your test results must be in your clinical record. Your clinical record will also include any summary of your diagnosis, condition, treatment plan, symptoms, prognosis, or treatment progress. Psychotherapy notes may be disclosed by a therapist only after you have given written authorization to do so. (Limited exceptions exist, e.g. in order for your therapist to prevent harm to yourself and others, and to report child abuse/neglect.) You cannot be required to authorize the release of your psychotherapy notes in order to obtain health insurance benefits for your treatment, or enroll in a health plan. Psychotherapy notes are also among the records that you may request to review or copy, unless we judge it would be harmful to yourself or others. If you have any questions, feel free to discuss this subject with your therapist.
This notice will go into effect on May 1, 2008. I reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that I maintain. The amended terms shall apply to all health information that I maintain, including information about you collected or obtained before the effective date of the revised information. I will provide you with a revised Notice by posting the revised Notice in the waiting are, on my website, and make copies available to my patients and others.
These pages are solely for public informational purposes. The information cannot be relied on to make diagnoses or prescribe treatment in any individual. Persons who require such services should consult with a licensed professional. If this is a medical emergency call 911 or go to the nearest emergency room immediately.