Douglas Tilley, LCSW-C, 1 Annapolis Street, Suite 100, Annapolis, MD (410) 268-4072
Notice of Policies to Protect the Privacy of Your Health Information
I. Uses and Disclosures of Information 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 written authorization. To help clarify these terms, here are some definitions:
"PHI" refers to information in your health record that could identify you.
– 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 mental health provider.
– 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.
·"Authorization" is 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 Requiring Authorization
I 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 I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information.
You may revoke all such authorizations of PHI 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, law provides the insurer the right to contest the claim under the policy.
III Uses and Disclosures without Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
·Child Abuse – If I have reason to believe that a child has been subjected to abuse or neglect, I must report this belief to the appropriate authorities.
IV. Patient’s Rights and Psychotherapist’s Duties
to Request Restrictions – You have the right to
request restrictions on certain uses and disclosures of protected health
information. 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. On 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 for PHI.
· 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. 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.
Mental Health Provider’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.
If you are concerned that I have violated your privacy
rights, or you disagree with a decision I made about access to your records,
please contact me.
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.
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. Upon request, I will
provide you with a revised notice in person or by mail.
Thank you, Douglas Tilley, LCSW-C April 14, 2003
Copyright © 2003 Douglas Tilley. All rights reserved.
Last modified: October 11, 2003