Hipaa Notice Form

Notice of Therapists’ Policies and Practices to Protect the Privacy of Your Health Information

BY SIGNING THE FIRST PAGE OF THE CLIENT INTAKE FORM, YOU ACKNOWLEDGE THAT YOU HAVE READ THIS DOCUMENT.

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

Your therapist 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 your therapist provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another therapist.
  – Payment is when C4VL obtains reimbursement for your healthcare. Examples of payment are when your therapist 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 your therapist’s 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 your therapist’s [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of your therapist’s [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
• Records are maintained on computer; fax and electronic transmission is utilized on an ongoing process, not a one-time occurrence.

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II. Uses and Disclosures Requiring Authorization

Your therapist may use or disclose PHI for purposes outside of treatment, payment, or 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 your therapist is asked for information for purposes outside of treatment, payment or health care operations, they will obtain an authorization from you before releasing this information. They will also need to obtain an authorization before releasing your Psychotherapy Notes, which may only be done under certain circumstances. “Psychotherapy Notes” are notes your therapist has made about our conversation during a private, group, joint, or family counseling session, which they 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, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

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

• Child Abuse – If they have reasonable cause to know or suspect that a child has been subjected to abuse or neglect, they must immediately report this to the appropriate authorities.
• Adult and Domestic Abuse – If they have reasonable cause to believe that an at-risk adult has been mistreated, self-neglected, or financially exploited and is at imminent risk of mistreatment, self-neglect, or financial exploitation, then they must report this belief to the appropriate authorities.
• Health Oversight Activities – If the Colorado State Board or DORA or an authorized professional review committee is reviewing their services, they may disclose PHI to that board or committee.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and they will not release information without your written authorization or a court order. The privileged does not apply when you are being evaluated or 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 you communicate to your therapist a serious threat of imminent physical violence against a specific person or persons, they have a duty to notify any person or persons specifically threatened, as well as a duty to notify an appropriate law enforcement agency or by taking other appropriate action. If they believe that you are at imminent risk of inflicting serious harm on yourself, they may disclose information necessary to protect you. In either case, they may disclose information in order to initiate hospitalization.
• Worker’s Compensation – They may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar

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programs, established by law, that provided benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Therapists’ Duties

Patient’s Rights:

• Right to Terminate Services or Therapy- If you wish, your therapist can provide you

with the names and phone numbers of other qualified mental health professionals or you

can cease treatment all together.