privacy policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS  INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.

A printable PDF version of this policy can be found in the client registration packet. CLICK HERE to download.

I am required by applicable federal and state law to maintain and safeguard the privacy of your Protected Health Information (PHI).  PHI is information in any format (electronic, paper, or verbal), about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition or the payment or provision of related health care services to you. I am required to provide you with this Notice about my privacy procedures. This notice must explain when, why, and how your PHI may be used or disclosed, my legal duties, and your rights concerning your PHI. I must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 23, 2013 and will remain in effect until further notice. I reserve the right to change the privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may also request a copy of this notice from me, or you can view a copy of
it in my office.

I. Uses and Disclosure of Your Protected Health Information (PHI)
I may use and/or disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of uses and disclosures, with some examples. Except for the purposes described below, your PHI will be disclosed only with your written permission. You may revoke such permission at any time in writing.
A. For treatment. 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 physician, psychiatrist, another psychologist or other licensed healthcare provider who provides you with health care services or are otherwise involved in your care.
B. For health care operations. 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. I may also provide your PHI to business associated (attorneys, accountants and consultants) with whom I have written agreements containing terms to protect the privacy of your PHI.
C. To obtain payment for treatment. Your PHI may be disclosed to bill and collect payment for the treatment and services provided to you. Example: I may send your PHI to your insurance company or health plan in order to determine eligibility, obtain authorization for continued services, and/or receive payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office. My policy is to provide the minimum amount of information that the insurance company needs to pay your benefits.
D. Other disclosures. Examples: Your consent is not required if you need emergency treatment provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.

SPECIAL SITUATIONS
1. Required by Law. Your PHI may be disclosed when/if required to do so by international, federal, state or local law. This includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
2. Abuse and Neglect Reporting. If I have reasonable cause to believe a child or individual (who is protected by state law) may be abused, neglected or financially exploited, I must report this belief to the appropriate authorities.
3. To Avert a Suicide or Violence/Homicide. I may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. If such a situation does come up, I will do my best to discuss the situation with you before I intervening, unless there is a very strong reason not to.
4. Health Oversight Activities. I may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
5. Health related benefits or services. Examples: I may disclose your PHI in order to obtain information about alternative treatment options, or other health care services or benefits.
6. Data Breach Notification Purposes. I may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.
7. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, I may be required to disclose PHI in response to a court or administrative order. If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law and can not be released without a court order. I can release the information directly to you upon your request. Information about all other psychological services is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.
8. Law Enforcement. I may be required to release PHI if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, I am unable to obtain the person's agreement; (4) about a death I believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
9. National Security and Intelligence Activities. If mandated to do so, I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States other authorized persons or foreign heads of state or to conduct special investigationsor assisting with intelligence operations, counter-intelligence, and other national security activities authorized by law.
10. Workers' Compensation. We may disclose your PHI as authorized to comply with workers' compensation laws and other similar legally-established programs.

II. USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT.
In all instances--unless mandated by law, in a crisis situation or otherwise noted above—I will obtain your written permission before releasing your PHI. You have the right to opt out and object to uses and disclosures.

III. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
Other uses and disclosures of PHI not covered by this Notice or the laws that apply will be made only with your written authorization. If you sign an authorization, you may revoke it at any time by submitting a written revocation and I will no longer disclose PHI under the authorization. Disclosure that I made in reliance on your authorization before you revoked it will not be affected by the revocation.

IV .THESE ARE YOUR RIGHTS WITH RESPECT TO PHI
1. Right to Inspect and Request Copies of PHI. You have a right to inspect and request a copy of PHI that may be used to make decisions about your care or payment for your care. This includes medical and billing records and progress notes. To inspect and copy your PHI, you must make your request, in writing. Your request will be responded to within 30 days. A reasonable fee for the administrative costs (i.e., copying, mailing) or for other supplies associated with the request. Your request may be denied in certain limited circumstances. If your requested is denied, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request.
2. Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. Every
effort to provide you access to your PHI in the form or format you requested will be made if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in a readable hard copy form. A reasonable fee may apply. The cost-based fee would be for the labor/conversion associated with transmitting the electronic medical record.
3. Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a) use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
4. Right to Amend Your PHI. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of receiving your request. Your request may be denied for reasons including: it was determined that the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not Connie Martin, Ph.D., Clinical Psychologist Client Registration Packet part of this offices records, or (d) written by someone other than Connie Martin, PhD. Such a denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and the denial be attached to any future disclosures of your PHI. If your request is approved, change(s) to your PHI will be made.
5. Right to Choose How Your PHI Is Sent to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). Most requests can be fullfilled and your PHI can be provided to you in the format you requested. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.
6. Right to an Accounting of Disclosures. If any disclosures of your PHI for purposes other than treatment, payment and health care operations or for which you provided written authorization were made; you would have the legal right to request a list of these disclosures in writing. However, as a practical matter, all disclosures of your health information that would be made related to your treatment or payment would have been authorized by you in writing, unless these disclosures were legally required.
7. Right to Request Limits and Restrictions on the Use and Disclosure of Your PHI. You have the right to request a restriction or limitation on the PHI used or disclosed for treatment, payment, or health care operations. You also have the right to request a limit on the PHI that is disclosed to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that information not be shared about a particular diagnosis or treatment with your parents, spouse or partner. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that are legally required or that I am permitted to make. To request a restriction, please specify this restriction in writing on your release of information form. I am not required to agree to a restriction you request.
8. Right To Restrict Disclosures When You Have Paid For Your Care: Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that I not bill your health plan) in full for a specific service, you have the right to ask that your PHI with respect to that service not be disclosed to a health plan for purposes of payment or health care operations.
9. Right to Request Confidential Communications. To request confidential communications, you must make your request, in writing. Your request must specify how or where you wish to be contacted. I will accommodate reasonable requests.
10. Right to Request This Notice by Email and/or Request a Paper Copy. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.

V. FOR YOUR INFORMATION
1.One Set of Progress Notes. I maintain one form progress note about your treatment. Should there be a reason for me to maintain two sets of progress notes I will inform you. Each set of notes requires a separate signed release of authorization.
2. No Marketing, Sale or Fundraising. Your PHI will not be used or sold for marketing purposes or fundraising purposes.
3. COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with Connie Martin, PhD or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.