TELEPHONE COUNSELING 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 OBTAINED DURING OUR TELEPHONE COUNSELING SESSION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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

I may use or disclose your protected health information (PHI) for counseling, 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.
• “Counseling, Payment and Health Care Operations”
  • Counseling is when I provide, coordinate or manage your health care and other services related to your health care. An example of counseling 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 credit card company 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 my 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 counseling, 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 counseling, 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 counseling notes. “Counseling notes” are notes I have made about our conversation during a private, group, joint, or family telephone counseling session, which I have kept separate from the rest of your counseling record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or counseling 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 credit card charges.

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, in my professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child's health or welfare (including sexual abuse), or from neglect, including malnutrition, I must immediately report such condition to your State Department of Social Services.
  
• Adult and Domestic Abuse: If I have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, I must immediately make a report to your State Department of Elder Affairs.
  
• Health Oversight: The Board of Registration of Psychologists has the power, when necessary, to subpoena relevant records should I be the focus of an inquiry.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and counseling and the records thereof, such information is privileged under state law and I will not release information without written authorization from you or your 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. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety: If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and I believe telephone counseling is not appropriate for you, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
  
• Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.

IV. Patient's Rights and Psychologist'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 Receive Confidential 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 me. 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 both) of PHI and counseling 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. 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 request and denial process.
  
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. 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.

Psychologist’s Duties:

• 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 provide notice by mail.

V. Complaints

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 contact your local Psychology Board.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Board listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on one week following the date on which notice is mailed.

I will limit the uses or disclosures that I will make as follows: only disclosures required by law.
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 provide you with a revised notice by mail

Signature,

_________________________________

Return to:
Dr Herman Lowe
160 Pine Street, Suite 10
Auburndale
MA 02466