Notice of Mental Health 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 ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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

INTROSPECT 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 INTROSPECT 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 psychiatrist, family physician or another psychologist.
    - Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we 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 our 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 INTROSPECT, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of INTROSPECT, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

INTROSPECT 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 INTROSPECT is asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes.
“Psychotherapy notes” are notes your provider has made about our conversation during a private, group, joint, or family counseling session. 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) INTROSPECT has 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

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

  • Child Abuse: If your provider has reasonable cause, on the basis of their professional judgment, to suspect abuse of children with whom they come into contact in their professional capacity, they are required by law to report this to the Pennsylvania Department of Public Welfare.
  • Adult and Domestic Abuse: If your provider has reasonable cause to believe that an older adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), they 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 we provided you or the records thereof, such information is privileged under state law, and we 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 your provider determines that you are likely to carry out the threat, they 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, we will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis.
  • Collections: You will be notified if there are any overdue outstanding balances in your account. Failure to settle your account in a reasonable period of time will result in your account being turned over to a collection agency. In such instances, your PHI will not be released with the exception of your name with identifying information, dates of services provided, and balance due.

IV. Patient's Rights and Provider’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, your provider is 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 being seen at INTROSPECT. Upon your request, INTROSPECT 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 INTROSPECT’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. 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 an amendment of PHI for as long as the PHI is maintained in the record. Your provider may deny your request. On your request, your provider 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, your provider 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 this notice from INTROSPECT upon request, even if you have agreed to receive the notice electronically.

INTROSPECT’s Duties:

  • We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
  • We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
  • If we revise our policies and procedures, we will provide you with a revised notice at your next visit or by mail if you are not currently in treatment here.

V. Complaints

If you are concerned that INTROSPECT has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact INTROSPECT’s Privacy Officer or Medical Director, Dr. Williard Shanken at our main number.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person 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 April 14, 2003.

INTROSPECT may limit the uses or disclosures of your PHI if you have an unpaid balance for any services we have provided to you. This restriction does not apply to instances where disclosure is required by law or, when in good faith, to use or disclose to avert a serious threat to health or safety of a person or the public and such use or disclosure is made to a person or persons reasonably able to prevent or lessen the threat of harm.

INTROSPECT reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice at your next office visit or in writing to your address listed on file.

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