Notice of Privacy Policy

�� Psychology and Social Work Clinic

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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, AND SIGN THE ACKNOWLEDGMENT OF RECEIPT.

Protecting Your Personal and Health Information

�� and the Psychology and Social Work Clinic are committed to protecting the privacy of client personal and health information. Applicable Federal and State laws require us to maintain the privacy of our clients’ personal and health information. This Notice explains our Clinic’s privacy practices, our legal duties, and your rights concerning your personal and health information. In this Notice, your personal or protected health information (PHI) is referred to as “health information” and includes information regarding your health care and treatment with identifiable factors such as your name, age, address, income, or other financial information. We will follow the privacy practices described in this Notice while it is in effect. This Notice takes effect September 23, 2013. This Notice will remain in effect until replaced.

How We Protect Your Health Information

We protect your health information by:

Treating all of your health information that we collect as confidential. (For exceptions to confidentiality, please see the following page and refer to your copy of the Disclosure Statement).
Stating confidentiality policies and practices in our Clinic Policy and Procedure Manual, as well as applying discretionary measures for privacy violations.
Restricting access to your health information only to those clinical staff who need to know your health information in order to provide services to you.
Only disclosing the minimum of your health information necessary for an outside service company to perform its function on the Clinic’s behalf; such companies have by contract agreed to protect and maintain the confidentiality of your health information.
Maintaining physical, electronic, and procedural safeguards to comply with federal and state regulations guarding your health information.

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

The Psychology and Social Work Clinic may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes, as long as you have given your consent to receive evaluation or treatment services from the Clinic. To help clarify these terms, here are some definitions:

“Treatment, Payment, and Health Care Operations”

Treatment is when a clinician provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when a clinician consults with another health care provider, such as your family physician.

Payment is when you provide reimbursement for the services you receive in the Clinic.

Health Care Operations are activities that relate to the performance and operation of the Clinic. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management and care coordination, conducting training and educational programs (supervision, case conference) or accreditation activities (such as the American Psychological Association site visits).

“Use” applies only to activities within the Psychology and Social Work Clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of the Clinic, such as releasing, transferring, or providing access to information about you to other parties.

Uses and Disclosures Requiring Authorization

The �� Psychology and Social Work Clinic may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when the Clinic is asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. In those instances, you must sign a consent form to release protected health information before PHI is released. In addition, you must sign an authorization consenting to the use or disclosure of psychotherapy notes for any reason.

You may revoke all such authorization at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that the Clinic has relied on that authorization to provide your services.

Uses and Disclosures with Neither Consent nor Authorization

The Psychology and Social Work Clinic may use or disclose PHI without your consent or authorization in the following circumstances:

Abuse – If we have reason to believe that a minor child, elderly person, or disabled person has been abused, abandoned, or neglected, the Clinic must report this concern or observations related to these conditions or circumstances to the appropriate authorities.
Health Oversight Activities – If the �� State Board of Psychology or other licensing or accrediting body is investigating a clinician that you have filed a formal complaint against, the Clinic may be required to disclose protected health information regarding your case.
Judicial and Administrative Proceedings as Required - If you are involved in a court proceeding and a court subpoenas information about the professional services provided to you and/or the records thereof, we may be compelled to provide the information. Although courts have recognized a therapist-client privilege, there may be circumstances in which a court would order the Clinic to disclose personal health or treatment information. The Clinic will not release information unless we have a written authorization from you or your legally appointed representative; the Clinic will release information if we are presented with a court order. The privilege does not apply when you are being evaluated for a third party (e.g., Law Enforcement agency or Social Security) or where evaluation is court ordered.
Serious Threat to Health or Safety – If you communicate to Clinic personnel an explicit threat of imminent serious physical harm or death to identifiable victim(s), and we believe you may act on the threat, we have a legal duty to take the appropriate measures to prevent harm to that person(s), including disclosing information to the police and warning the victim. If we have reason to believe that you present a serious risk of physical harm or death to yourself, we may need to disclose information in order to protect you. In both cases, we will only disclose what we feel is the minimum amount of information necessary.
Worker’s Compensation – The Clinic may disclose protected health information regarding you as authorized by, and to the extent necessary to comply with, laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
National Security – We may be required to disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may be required to disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may be required to disclose health information to a correctional institution or law enforcement official having lawful custody of protected health information of an inmate or patient under certain circumstances.
Research - Under certain limited circumstances, we may use and disclose health information for research purposes. Your authorization will be secured for these uses/disclosures of your information. In addition, all research projects are subject to review by the �� Institutional Review Board (IRB)

Client Rights and Psychologist’s Duties

Client Rights:

Right to Request Restrictions – You have the right to request additional restrictions on certain uses and disclosures of protected health information (PHI). The Psychology and Social Work Clinic may not be able to accept your request, but if we do, we will uphold the restriction unless it is an emergency. You have the right to restrict the disclosure of your PHI to your insurance company if you pay out-of-pocket for your services in full.
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 you are being seen at the Clinic. On your request, the Clinic will communicate with you at another address.)
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of your Clinic records. A reasonable fee may be charged for copying. Access to your records may be limited or denied under certain circumstances, but in most cases you have a right to request a review of that decision. On your request, we will discuss with you the details of the request and denial process.
Right to Amend – You have the right to request in writing an amendment of your health information for as long as PHI records are maintained. The request must identify which information is incorrect and include an explanation of why you think it should be amended. If the request is denied, a written explanation stating why will be provided to you. You may also make a statement disagreeing with the denial, which will be added to the information of the original request. If your original request is approved, we will make a reasonable effort to include the amended information in future disclosures. Amending a record does not mean that any portion of your health information will be deleted.
Right to An Accounting – You generally have the right to receive an accounting of disclosures of PHI. If your health information is disclosed for any reason other than treatment, payment, or health care operation, you have the right to an accounting for each disclosure of the previous six (6) years. The accounting will include the date, name of person or entity, description of the information disclosed, the reason for the disclosure, and other applicable information. If more than one (1) accounting is requested in a twelve (12) month period, a reasonable fee may be charged.
Electronic vs. Paper Copy – You have the right to request information from your records electronically. If you request records that exist in an electronic format, you have the right to receive records in an electronic format rather than a paper copy.
Right to Notification of Breach – You have the right to be notified if the privacy of your protected health information has been breached.
Right to Opt-Out – The Clinic does not currently engage in direct fundraising or marketing mailings. If the Clinic were to engage in such mailings in the future, you have the right to opt out of any fundraising or marketing mailings.

�� Psychology and Social Work Clinic Duties:

The Psychology and Social Work Clinic is required by law to maintain the privacy of PHI and to provide you with this notice of legal duties and privacy practices.
The Clinic and University reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, the Clinic is required to abide by the terms currently in effect.

Other Restrictions

The Psychology and Social Work Clinic must also conform to Federal regulations (42 CFR, Part 2) regarding the release of alcohol/drug treatment records and confidentiality standards related to such treatment.
In addition, couples and families seeking conjoint treatment sign a supplemental consent indicating they understand that the record of treatment services provided will not be released without authorization from all adults present.

Changes to this Notice

�� and the Psychology and Social Work Clinic reserve the right to change our privacy practices and terms of this Notice at any time, as permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make such changes, we will update this Notice and post the changes in the Clinic waiting room. You may request a copy of this Notice at any time.

Questions and Complaints

For questions regarding this Notice or our privacy practices, please contact the Psychology and Social Work Clinic Director.

If you are concerned that your privacy rights may have been violated, you may contact the Clinic Privacy Officer listed below to make a complaint. You may also make a written complaint to the U.S. Department of Health and Human Services whose address can be provided upon request. If you choose to make a complaint with the U.S. Department of Health and Human Services, or with us, we will not retaliate in any way.

�� Psychology and Social Work Clinic Director: Megan Austin, Ph.D.

Address: ��, Porter Hall Room 002, Athens, �� 45701-2979

Telephone: 740-597-1251

#158-03 HIPAA Rev,12-03, 9-09, 09-13

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