and confidentiality of our visits is an important concern to me. I am
conscientious in my efforts to preserve and maintain your privacy at all times.
Please feel free to ask me about any concerns you may have about this matter. In
addition to the measures that I have always maintained to protect your privacy,
I am now required by Federal law to provide to you the following notice.
is in compliance both with California law and with the new Federal Health
Insurance Portability and Accountability Act (HIPAA) providing new privacy
protection and new patient rights with regard to the use and disclosure of your
Protected Health Information (PHI) used for the purpose of treatment, payment
and health care operations. This notice is based on the American Psychological
Association model for compliance with the new requirements.
CALIFORNIA 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 may use or disclose your protected
health information (PHI), for
certain treatment, payment, and health care operations purposes without your
authorization. (See Section VI
on the last page of this document indicating the limitations that I place upon
such disclosures in my practice, which provides greater privacy protection for
you). In certain circumstances I can only do so when the person or
business requesting your PHI gives me a written request that includes certain
promises regarding protecting the confidentiality of your PHI. To help clarify
these terms, here are some definitions:
Treatment is when I provide or another
healthcare provider diagnoses or treats you. An example of treatment would be
when I consult with another health care provider, such as your family physician
or another psychologist, regarding your treatment.
– 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 is when I disclose your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
I may use
or disclose PHI for purposes outside of treatment, payment, and health care
operations when your appropriate authorization is obtained.
In those instances when I am asked for information for purposes outside
of treatment and payment 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.
revoke or modify all such authorizations (of PHI or psychotherapy notes) at any
time; however, the revocation or modification is not effective until I receive
Uses and Disclosures with Neither Consent nor Authorization
I may use
or disclose PHI without your consent or authorization in the following
Abuse: Whenever I, in my professional
capacity, have knowledge of or observe a child I know or reasonably suspect, has
been the victim of child abuse or neglect, I must immediately report such
to a police department or sheriff’s department, county probation department,
or county welfare department. Also, if I have knowledge of or reasonably suspect that
mental suffering has been inflicted upon a child or that his or her emotional
well-being is endangered in any other way, I may report such to the above
and Domestic Abuse: If I, in my
professional capacity, have observed or have knowledge of an incident that
reasonably appears to be physical abuse, abandonment, abduction, isolation,
financial abuse or neglect of an elder or dependent adult, or if I am told by an
elder or dependent adult that he or she has experienced these or if I reasonably
suspect such, I must report the known or suspected abuse immediately to
the local ombudsman or the local law enforcement agency.
do not have to report such an incident if:
1) I have been told by an elder or dependent adult that he
or she has experienced behavior constituting physical abuse, abandonment,
abduction, isolation, financial abuse or neglect;
2) I am not aware of any independent evidence that
corroborates the statement that the abuse has occurred;
3) the elder or dependent adult has been diagnosed with a
mental illness or dementia, or is the subject of a court-ordered conservatorship
because of a mental illness or dementia; and
in the exercise of clinical judgment, I reasonably believe that the abuse did
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 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 notify you as indicated in section VI below.
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. I will notify you prior
to releasing any information based upon the revision, either by US mail or by
giving you a revised notice personally during an office visit.
VII. Limitations of Disclosure
I will limit the uses or
disclosures that I will make as follows:
If you have authorized me to bill
an insurance carrier or other third party I will disclose to such third party or
parties only the information required to determine eligibility, benefits and
reimbursement for my services under your plan. If you have authorized
reimbursement under a managed care plan, I will disclosure only the information
required by that plan to authorize your sessions. If you have given me the names
of other therapists or physicians who are treating you, I will disclose
information to them only if you have requested that I do so, and have signed an
authorization form permitting me to do so. If you have any questions about these
limitations, or anything else on this form, please feel free to ask me about