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Notice of Privacy Practices

This Notice Describes How Medical Information about You May be Used and Disclosed and How You can get Access to this Information. (Please Review Carefully)

This Notice will tell you how I use your Protected Health Information (PHI) in this office, how I share it with other professionals and organizations, and how you can see it. Privacy is a very important concern in receiving mental health services. It is affected by federal and state laws, and professional ethical principles and code of conduct. The rules are complicated. If you have questions, I will be happy to help you understand my procedures and your rights.

A. What is Meant by Your "Protected Health Information" (PHI)

Each time you visit me (or any doctor's office, hospital, clinic, or any other what are called "healthcare providers"); information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the tests and treatment you got from me or from others, or about payment for healthcare. The information I collect from you is called, in the law, Protected Health Information (PHI). This information goes into your medical or healthcare record or, in my office, into your file.

In my office, this PHI is likely to include these kinds of information:

Your PHI is used for many purposes. Many of these require your authorization. For example, I may use it:

When you understand what is in your record and what it is used for, you can make better decisions about whom, when, and why others should have this information.

Your health record is the physical property of the healthcare practitioner or facility that collected it, but the information belongs to you. You can read it. You may have a copy. There is a charge for the cost of copying and mailing, (if you want it mailed to you). In some rare situations, you cannot see everything in your record.

If you find anything in your records you think is incorrect, or believe that something important is missing, you can ask me to amend (add information to) your record. In some rare situations, I do not have to agree to do that. If you want, I can explain more about this.

B. Privacy and the Laws About Privacy

I am also required to tell you about privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The HIPAA law requires me to keep your Protected Health Information (PHI) private and give you this notice of my legal duties and my privacy practices, which is called the Notice of Privacy Practices (NPP). I will obey the rules of this notice as long as it is in effect, but if I change it, the rules of the new NPP will apply to all the PHI I keep. If I change the NPP, I will post the new Notice in my office where everyone can see, or will provide all of my clients with a copy of the amended NPP. You or anyone else can get a copy from me anytime.

C. How your Protected Health Information Can be Used and Shared

When your information is read by me or used to make decisions about your care, that is called, in the law, "use." If the information is shared with, or sent to, others outside this office, that is called "disclosure." Except in some special circumstances, when I use your PHI or disclose it to others, I share only the minimum necessary PHI needed for those other people to do there jobs. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed (shared). Therefore, I will tell you more about what I do with your information.

I use and disclose PHI for several reasons. Most of these are routine, as explained immediately below. For other uses, I must obtain specific additional written authorization from you, unless the law lets or requires me to make the disclosure without authorization. There are some uses and disclosures that do not need your consent or authorization.

1.Routine Uses and Disclosures of PHI in Healthcare with Signed Consent to Use and Disclose PHI

After you have read this Notice, you will be asked to sign a "Consent to Use and Disclose Your Protected Health Information" (PHI) form that allows me to use and disclose your PHI for routine purposes. Your PHI is usually used to provide treatment, arrange for payment for services, and other business functions called health care options (TPO: Treatment, Payment, and Healthcare Operations). The consent form allows me to use and disclose your PHI for these routine purposes. You must sign the consent form before I begin to treat you because if you do not consent, I cannot collect the information, use it, and share it as necessary to promptly treat you.

a. For Treatment:

I use your medical information to provide you with psychological treatment and treatment and services, such as individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the benefits of my services. The findings provided to me from other providers also will go into your records here.

b. For Payment

Your PHI may be used to bill you, your insurance, or others. I contact insurance companies to learn of mental health coverage. I may have to tell your insurance company diagnoses, treatment received, meeting times, changes I expect in your condition, progress, etc. Insurance companies usually claim to keep psychological diagnoses confidential, but may enter this information into national medical information databanks, where it may be accessed by employers, other insurance companies, etc., and may limit future access to disability insurance, life insurance, jobs, etc. Your therapist will provide you with copies of reports submitted to insurance companies at your request.

If health coverage is provided by an employer, the employer may have access to such information.

I reserve the right to refuse financial information to a collection agency, attorney, or small claims court, if you are delinquent in paying your bill. 

c. For Health Care Operations:

Your PHI may be used to see where I can make improvements in the care and services I provide. I may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If I do, your name and personal information will be removed what I send.

d. Other Uses in Healthcare:

Appointment Reminder. I may disclose your PHI to reschedule or remind you of your appointments. Significant others often retrieve such voice mail messages. If you want me to call or write to you only at home or work or prefer some other way to reach you, I usually can arrange that.

Welfare Checks. If I am concerned with your well-being, I may contact you at home or work. If it is urgent, so I cannot ask if you disagree, I may share information that I believe will help you, or that I believe you would have wanted me to share. If I do share information, in an emergency, I will tell you as soon as I can. If you don't  approve, I will stop, as long as it is not against the law. Please indicate if you would like to limit such contacts.

Treatment Alternatives. I may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of help to you.

Other Benefits and Services. I may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.

Research and Education. Your PHI may be used for research or educational purposes (teaching, writing, supervision), with your name, address and other personal identifiers removed. If researchers want to know who you are, I will discuss the research project with you and information will be shared if you sign a special authorization form. Please indicate if you wish to place restrictions on research or education related to your case.

Business Associates. Business associates are services hired for specific jobs, such as a copy service to make copies of your health record, or a billing service that figures out, prints, and mails my bills. These business associates need to receive some of your PHI to do their jobs properly. They agree in their contract with me to safeguard your PHI.

2. Uses and Disclosures that Require Your Additional, Specific, Written Authorization to Release PHI

If you want me to use your PHI for purposes other than the routine uses described above, you must sign an additional authorization form; "Client Authorization to Release Confidential Personal Health Information (PHI)". For example, it is common practice for psychotherapy clients to authorize disclosure of PHI to other mental health and health care providers involved in their care to coordinate treatment. Often, psychotherapy clients wish the therapist to share some PHI with particular loved ones. You can revoke (cancel) that permission, in writing, at any time. After that time, I will not use or disclose your information for the purposes that we agreed to. Of course, I cannot take back any information I had already disclosed with your permission or that I had used in my office.

3. Uses and Disclosures of PHI from Mental Health Records that do Not Require Consent or Authorization

The laws let me use and disclose some of your PHI without your consent or authorization in some cases. Here are examples of when I might have to share information.

a. I am required to release PHI obtained from you or collateral sources (other individuals involved in your treatment, e.g., parents, guardians, spouses) to appropriate authorities to the extent such disclosure may help avert danger to you or to others, e.g.; imminent risk of suicide, homicide, or destruction of property that could endanger others.

b. I  am required to report suspected past or present abuse or neglect of children, adults, and elders, to the authorities, including Child Protection and law enforcement, based on information provided by the client or collateral sources.

c. If clients participate in psychotherapy in compliance with a court order, I am required to release information to the relevant court, social service, or probation departments.

d. I  am required to provide information in response to court orders and, in some cases, to subpoenas and discovery requests. I will attempt to notify you of such requests. If you wish to protect your PHI, I will work with you to do so. However, the court may override your right to protect your PHI. In some kinds of proceedings, courts order entire psychotherapy record to be provided.

e. I may have to release your PHI if asked to do so by a law enforcement official to investigate a crime or criminal.

f. I will have to release your PHI if I suspect that you, or people involved in your life, may commit a crime against me, or people involved in my life, or have committed such a crime.

g. I may have to disclose your PHI of military personnel and veterans to the government benefit programs relating to eligibility and enrollment.

h. In some cases, I may have to disclose your PHI to Workers Compensation and Disabilities programs.

i. I may have to disclose your PHI for national security reasons.

j. I may have to disclose some of your PHI to government agencies that check on compliance with privacy laws.

4. Cell Phone and E-mail Communication

There may be an occasion for us to have a cell phone or e-mail communication with each other. These can be intercepted by third parties. E-mail should be encrypted for your protection and should be reserved for urgent or time-sensitive matters. I make a record of each contact. E-mail communication is printed in full and becomes part of your PHI.

5. Routine Progress Notes and Process Notes

Routine Progress Notes are my record of your routine PHI, such as history, symptoms, assessment and diagnosis, treatment plan, progress, prognosis, records/reports by other providers, medications, and billing/insurance information. Process Notes include details of particularly sensitive information you provide and notes to myself to test hypothesis, help me contact, etc. Process notes are kept in a separate file or designated as "Process Notes". You only have access to process notes if I permit it. Other parties can rarely obtain access to these notes. If you wish to release process notes to other parties, this requires my permission and a separate signed authorization from you.

6. An accounting of disclosures

When I disclose your PHI, I may keep some records of whom I sent it, and what I sent. You may have an accounting (a list) of many of these disclosures.

D. Your rights regarding your health information

1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask me to call you at home, and at work, to schedule or cancel an appointment. I will try my best to do as you ask.

2. You have the right to ask me to limit what I tell people involved in your care or the payment for you care, such as family members and friends. While I don't have to agree to your request, if I do agree, I will keep our agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.

3. You have the right to look at the health information I have about you such as your medical billing records. You can even get a copy of these records, but there is a charge. Contact me to arrange how to see your records.

4. If you believe the information in your records is incorrect or missing important information, you can ask me to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to me. You must tell me the reasons you want to make the changes.

5. You have the right to a copy of this notice. If I change this NPP, I will post the new version in the waiting area and you can always get a copy of the NPP from me.  

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.

Also, you may have other rights granted to you by the laws of our state and these may be the same or different from the federal rights described above. I will be happy to discuss these situations with you now or as they arise.

If you need more information or have questions about the privacy practices described above. Please speak to me at the telephone number listed below. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact me. You have the right to file a complaint with me and with the Secretary of the Department of Health and Human Services. I promise that I will not in any way limit your care here or take any actions against you if you complain.  

If you have any questions regarding this Notice or my health information privacy policies, please contact me at the phone number or address listed at the top of this document. The effective date of this notice is July 6, 2008.


| How Can You Benefit from Therapy?  |   Individual Therapy  |  Family Therapy  |  Play Therapy |
Who I Work With |  About Eric Terry | Fees | About Insurance | Privacy Policy | Contact | Home |