Pennsylvania Privacy Notice
of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ASSESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment,
and Health Care Operations.
I 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
- Treatment is when I provide,
coordinate or manage your health care and other services related to your health care. An example of treatment 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 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 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 [office, clinic, practice, group,
etc.] such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.
¨ “Disclosure” applies to activities outside of my [office, clinic,
practice, group, etc.] such as releasing, transferring, or providing access to information about you to other
II. Uses and Disclosures Requiring
I may use or disclose PHI for purposes outside
of treatment, 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 treatment, payment and health care operations, I will obtain an authorization
before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation
during a private, group, joint or family counseling session, which I 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, and the law provides the insurer the right to contest the claim under the policy.
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 have reasonable cause, on the basis
of my professional judgement, to suspect abuse of children with whom I come into contact in my professional capacity.
I am required by law to report this to the Pennsylvania Department of Public Welfare.
Adult and Domestic Abuse: If I have reasonable cause to believe that
an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), I may report such
to the local agency which provides protective services.
¨ Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made
about the professional services I provided you or the records thereof, such information is privileged under state law, and
I will not release the information without your written consent, 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 express a serious threat, or intent to kill or seriously injure
an identified or readily identifiable person or group of people, and I determine that you are likely to carry out the threat,
I must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim
of the threat or intent.
Worker’s Compensation: If you file a worker’s compensation claim,
I will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment,
IV. Patient’s Rights and Psychologist’s
¨ 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 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
¨ 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.
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 you with this
revised notice in your next scheduled session. If you have no completed session within once month of the revision, I
will send it to you.
If you are concerned that I have violated
your privacy rights, or your disagree with a decision I made about access to your records, you may contact me, Catherine S.
Spayd, Ph.D., for further information at the above address or telephone number.
You may also send a written complaint to the
Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.
VI. Effective Date, Restrictions and Changes
This notice will go into effect on April 14,
2003. 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 as described above.