of ACP Consultants' (ACP) Policies and Practices to Protect the
NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
and Disclosures for Treatment, Payment, and Health Care Operations
to information in your health record that could identify you.
and Health Care Operations"
when ACP provides, coordinates, or manages your health care and other
services related to your health care. An example of treatment would be when
ACP consults with another health care provider, such as your family physician or
- Payment is when ACP obtains reimbursement for your
healthcare. Examples of payment are when ACP discloses 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 the practice of
ACP. Examples of matters such as audits
and administrative services, and case management health
care operations are quality assessment and improvement activities,
business-related and care coordination.
only to activities within ACP [office, clinic, practice group, etc.] such as
employing, applying, utilizing, examining, and analyzing information that
to activities outside of ACP [office, clinic, practice group, etc.], such
as releasing, transferring, or providing access to information about you to
your written permission to disclose confidential mental health information.
All authorizations to disclose must be on a specific legally required form.
II. Other Uses and Disclosures
ACP may use or disclose PHI for
purposes outside of treatment, payment, or health care operations
when your appropriate authorization is obtained. In those instances when ACP is
asked for information for purposes outside of treatment, payment, or health care
operations, ACP will obtain an authorization from you before releasing
will also need to obtain an authorization before releasing your Psychotherapy
notes your ACP provider may have made about conversations during
a private, group, joint, or family counseling session, which your ACP provider
has kept separate from the rest of your record. These notes are given a
greater degree of' protection than
You may revoke all such authorizations (or PHI or Psychotherapy Notes) at any time,
each revocation is in writing. You may not revoke an authorization to the extent
that (1) ACP has relied on that
authorization; or (2) if the authorization was obtained as a condition of
obtaining insurance coverage, law provides the insurer the right to contest the claim
under the policy.
Uses and Disclosures without Authorization
ACP may use or disclose PHI without your consent or
authorization in the following circumstances:
ACP provider has reasonable cause to believe a child known to me
in my professional capacity may be an abused child or a neglected child, he/she must report this belief to the appropriate authorities.
Domestic Abuse -If your ACP provider has reason to believe that an individual
(who is protected by state law) has been abused, neglected, or financially
exploited, he/she must report this belief to
the appropriate authorities.
Oversight Activities -
ACP may disclose protected health information regarding
you to a health oversight agency for oversight activities authorized by law, including
licensure or disciplinary actions.
Administrative Proceedings - 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
ACP must not release such information without a court order. ACP can release the information directly to you on 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.
Threat to Health or Safety -If you communicate to
your ACP provider a specific threat
of imminent harm against another individual or if your ACP provider believes
that there is clear, imminent risk of physical or mental injury being inflicted
against another individual, your ACP provider may make
disclosures that he/she believes are necessary to protect that individual from harm. If your ACP
provider believes that you present an
imminent, serious risk of physical or mental injury or death
to yourself; your ACP provider may make disclosures he/she considers necessary
to protect you from harm.
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
Patient's Rights and Psychologist's Duties
to Request Restrictions –
have the right to request restrictions on certain uses
and disclosures of protected health information. However, ACP is not required to
agree to a restriction you request.
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 an ACP provider.
On your request, ACP will send your bills to another address.)
to Inspect and Copy -
have the right to inspect or obtain a copy (or both) of
PHI in ACP's mental health and billing records used to make decisions about you for as
long as the PHI is maintained in the record
and Psychotherapy Notes. On your request, your ACP provider will discuss
with you the details of the request for access process.
to Amend- You have
the right to request an amendment of PHI for as long as the
PHI is maintained in the record. ACP may deny your request. On your request, your
ACP provider will discuss with you the details of the amendment process.
to an Accounting- You
have the right to receive an accounting of disclosures of PHI. On your request, your ACP
provider will discuss with you the details
of the accounting process.
to a Paper Copy -
the right to obtain a paper copy of the notice from me
upon request, even if you have agreed to receive the notice electronically.
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