Dr. Manjit Kaur Khalsa Ed.D.
MASSACHUSETTS
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 MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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 Care Operations”
– 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, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.
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 from you
before releasing this information. I
will also need to 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.
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 the Massachusetts 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 the Massachusetts 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 treatment 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
refuse to accept further appropriate treatment, 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.
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
psychotherapy 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 contact you by email, if possible, or by letter if no email is available.
If you
have questions about this notice, disagree with a decision I make about access
to your records, or have other concerns about your privacy rights, you may
contact __Dr. Manjit Kaur Khalsa Ed.D._(Privacy Officer)
If you
believe that your privacy rights have been violated and wish to file a complaint
with me/my office, you may send your
written complaint [or specify other method
for patients to file complaint with you] to ___Dr. M. Khalsa ED.d__(see
below for contact information).
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.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
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 by email, if possible, or by
letter if no email is available.
YOUR
SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS
TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA
NOTICE FORM DESCRIBED ABOVE.
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