Notice of Privacy Practices

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.

This notice explains how information is handled, how it can be reviewed, and how it is shared with other professionals and organizations. Licensed Educational Psychologists are required by law to disclose this information related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In most situations, information regarding services/treatment can only be released by providing a written authorization form that meets certain legal requirements imposed by state law or HIPAA. Clients who are 13 or older must also sign the written authorization form.

Protected Health Information (PHI)

At each meeting, information is collected about the client’s educational functioning; family history; and physical, adaptive, emotional, or mental health. This may include information about the client’s past, present, or future health or condition; the treatment or services received; or payment for health care. This information is called Protected Health Information (PHI). The information obtained from the client or parent/guardian is maintained (via paper and/or electronic) in a secure office location. It is likely to include the following:

• Personal and educational history
• Reasons for educational testing/treatment: problems, symptoms, needs, goals
• Diagnoses: medical terms for client presenting problems, symptoms, disabilities
• Treatment plan: services/interventions/accommodations for intervention
• Testing/interview notes
• Treatment or evaluation records from other providers/school
• Psychological test scores, protocols, school records, and the like
• Health history and medications
• Legal documentation and matters
• Billing information

This information is used for many purposes including, but not limited to:

• Evaluation plan
• Psychoeducational reports and recommendations
• Communication with other health care professionals (current/past) providing treatment (e.g., primary care physician)
• Billing and services rendered documentation

Although health records and documentation are the physical property collected by the treating health care practitioner, the information belongs to you. You can inspect, read, or review all records (parent of a child under the age of 18; child, if over 12 years of age; and/or child under 12, if the child is lawfully in treatment without parental consent).

Copies of records will be made available for you upon written request, and reasonable fees for the cost of copying and mailing may be charged. In some rare situations, you will be prevented from seeing all of what is in the records. Records will not be released in circumstances where it is deemed that disclosure of the contents of that file could reasonably be expected to be life threatening, endanger the safety of the client or another, or where disclosure could reasonably be expected to lead to your identification of the person who provided confidential information.

Records may include components that are of a professional and technical nature and may be misinterpreted or prove to be upsetting to an untrained reader. For this reason, it is recommended that records initially be reviewed with the LEP or forwarded to another mental health professional to discuss the contents. If your request for record review is denied, you have a right to review the reason for that denial. Anything in the records that may be incorrect or missing can be amended within the record, with agreement from both parties.

How Protected Health Information Can Be Used and Shared

When confidential information is read by the clinician or other clinicians for professional consultation (within office), it is called “use.” If the information is shared with or sent to others outside this office, it is called “disclosure.”

Except in some special circumstances, when client PHI is used or disclosed to others, only necessary information will be shared for the intended purpose. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

In almost all cases, the intent of sharing PHI in-office or with other people or organizations is to provide an evaluation for you or your child, arrange for payment for services, or conduct some other business activities called “health care operations.”

Information about you or your child is needed in order to provide satisfactory care and evaluative services. Informed consent is needed to allow collection of that information to use and share as necessary. Evaluation and treatment cannot commence without a signed Consent Form. If you do not agree and consent, the child cannot be evaluated. Other practice employees or contractors will follow the same legal guidelines. Generally, disclosure of PHI is for three purposes: treatment/evaluation, obtaining payment, and health care operations.

Treatment/Evaluation. Medical information may be utilized to provide you or your child with psychological services, evaluation, or treatment. This might include individual, family, or group therapy; psychological or educational testing; treatment planning; or measuring the effects of services.

Disclosure of you or your child’s PHI may be released to others who provide treatment to you or your child, including a physician. Occasionally it may be helpful to consult other medical and mental health professionals about a case. During consultation with a professional, who is not involved in your treatment, every effort is made to avoid revealing your identity. These professionals are legally bound to keep the information confidential. Consultations will not be disclosed to you, unless it is important to the work and all consultations will be noted in your clinical record.

At times it may be necessary to refer you or your child to other professionals or consultants for services within a different scope of practice, such as special testing or treatments. In these cases, an exchange of information will be completed in order to share information about you or your child’s conditions, as well as receive their findings and recommendations. This will be recorded in the clinical record and can be shared (with consent) to potential future medical and/or mental health professions.

Payment. Information will be utilized to bill for evaluation and services provided to you or your child.

Health Care Operations. Disclosure of information for you and/or your child’s PHI may be necessary in the course of operating various business functions. This may include, but is not limited to:

• evaluating the quality of mental health services provided to you
• developing clinical guidelines
• contacting you with information about treatment alternatives or communications in connection with your child’s case management or care coordination
• reviewing the qualifications and training of health care professionals
• conducting medical review, legal services, and auditing functions
• managing general administrative activities, such as customer service and data analysis

Unless you request to be contacted by other means, the Privacy Rule permits contact with you regarding appointment reminders and other similar materials.

“As a courtesy to clients, appointment reminders are made through phone calls to given numbers or email. In the event calls are unanswered, reminder messages will be left via voicemail or with the person answering the phone. No PHI will be disclosed during this conversation or message other than the date and time of your scheduled appointment and a request to return the call if you need to cancel or reschedule your appointment.”

Business associates who may assist with tasks such as billing, filing, and messages need to receive some of your or your child’s PHI in order to perform these services properly. To protect your privacy, you and your child’s information will be safeguarded.

II. Uses and Disclosures Requiring Your Authorization

In order to use you or your child’s PHI for any purpose besides those described above, written permission via an authorization form is required. If you do authorize use or disclosure of your or your child’s PHI, you can revoke that permission in writing at any time. Uses or disclosures prior to a revocation cannot be undone. Any information shared at your request about you or your child with family or personal contacts will be done based on information you choose to disclose.

III. Uses and Disclosures Not Requiring Your Consent or Authorization

Use and/or disclosure PHI without your consent or authorization will be done in the following circumstances:

• Child abuse. PHI information about you and/or your child will be disclosed if compelled by the California Child Abuse and Reporting Act. Licensed Educational Psychologists are mandated reporters and are required to report any observed or disclosed incidents where a child has been injured as a result of physical, mental, or emotional abuse; neglect; sexual abuse; or exposure to domestic violence. This includes knowledge of or reasonable suspicion that mental suffering has been inflicted upon a child or that his/her emotional well-being is endangered in any other way. This must be immediately reported to a police or sheriff’s department, social services, or protective service agency.
• Adult and domestic abuse. PHI information may be disclosed if it is compelled by the California Elder/Dependent Adult Abuse Reporting Law. This would include reasonable cause that an adult has been or is being abused, abandoned, abducted, isolated, neglected, financially exploited, or in need of protective services. This must be reported to the appropriate authorities as permitted or required by law.
• Health oversight activities. Disclosure of you and/or your child’s PHI information to the California Board of Psychology, California Board of Behavioral Sciences, or other oversight agency is necessary for a proceeding before these boards. PHI information may be used and/or disclosed in designated activities and functions including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions.
• Judicial and administrative proceedings. Disclosure of you and/or your child’s PHI may be warranted in response to an order of a court or administrative tribunal, a warrant, subpoena duces tecum, discovery request, or other lawful process. If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without 1) your written authorization or the authorization of your attorney or personal representative; 2) a court order; or 3) a subpoena duces tecum (a subpoena to produce records), where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered.
• Relating to decedents. Disclosure of you and/or your child’s PHI may be used if compelled or permitted, in the event of your death, to the coroner or medical examiner.
• Appointment reminders. As indicated above, you will be contacted without your prior authorization to provide appointment reminders at your preferred contact information (e.g., telephone, letter, mail, fax).
• To avert a serious threat to health or safety. If I believe there is a substantial likelihood that you have threatened an identifiable person or persons and that you/your child are likely to act on that threat, or if it is believed that you/your child present an imminent risk of serious physical harm or death to oneself, your PHI may be used and/or disclosed in order to avert a serious threat to health or safety.
• Worker’s compensation. Information may be disclosed about you and/or your child’s health information as necessary to comply with State Workers’ Compensation laws.
• Emergencies. Information may be disclosed about you and/or your child to assist in notifying a family member, relative, or another person responsible for your care about your psychological or medical condition or in the event of an emergency or of your death.
• U.S. Secretary of Health and Human Services. Information may be disclosed about you and/or your child’s PHI to the U.S. Secretary of Health and Human Services or the Office of Civil Rights if compelled to participate in an investigation or determination of my compliance with privacy, security, and transaction requirements under federal regulations.
• When required by law. Information may be used and/or disclosed about you and/or your child in other circumstances not described above when law specifically requires disclosure of this information.

Patient Rights

In summary, HIPAA and California State law provide you with certain rights regarding your/your child’s clinical record and disclosure of protected health information about you/your child. These rights include:

• Requesting amendments to your/your child’s record
• Requesting restrictions on what information from your/your child’s clinical record is disclosed to others
• Requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized
• Determining the location to which protected information disclosures are sent
• Requesting that any complaints made about clinician policies and procedures be noted in your records
• Receiving a copy of this Notice of Privacy Practices form

An Accounting of Disclosures

When you or your child’s PHI is disclosed, a record will be kept of what was sent, when it was sent, and to whom it was sent. You may ask for this information at any time.

If you need more information or have questions about these privacy practices, have a problem with how you or your child’s PHI has been handled, or if you believe your or your child’s privacy rights have been violated, please contact me immediately for discussion. You have the right to file a complaint about your concerns with the Secretary of the Federal Department of Health and Human Services. A complaint will not in any way limit you or your child’s care or result in any actions taken against you.

I [Name] am the designated privacy officer for my practice and can be reached by phone at [Phone Number] and by email at [Email Address].

This Notice went into effect on [Date].

HIPAA NOTICE OF PRIVACY PRACTICES

Client’s Name: __________________________________________

Client’s Date of Birth: ____________________________________

By signing below, I acknowledge I have received a copy of my/my child’s HIPAA Notice of Privacy Practices from [Your Name].

Name: _____________________________________________________________

Relationship to Client: _________________________________________________

Name: _____________________________________________________________

Relationship to Client: _________________________________________________

______________ _________________________________________

Date Signature of Client (if over age 13)

______________ _________________________________________

Date Signature of Parent/Guardian

______________ _________________________________________

Date Signature of Licensed Educational Psychologist as Witness