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GEORGIA
NOTICE FORM
Notice
of Psychologist's 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
The
staff of Beyond Words 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 the staff of Beyond Words provide, coordinate or manage
your health care and other services related to your health
care. An example of a time when we would use your PHI in treatment
would be in consultation with another health care provider,
such as your family physician or another psychologist, for
purposes of coordinating services.
- Payment
is when Beyond Words obtains reimbursement for the healthcare
services provided to you. Examples of disclosure of your PHI
in relation to payment include 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
which may involve disclosure of your PHI include 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 the Beyond Word practice. "Use"
includes sharing, employing, applying, utilizing, examining, and
analyzing information that may identify you.
- "Disclosure"
applies to activities outside of the Beyond Words practice, such
as releasing, transferring, or providing access to information
about you to other parties.
II.
Uses and Disclosures Requiring Authorization
Beyond
Words may use or disclose PHI for purposes outside of treatment,
payment, or 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 we are asked for information for purposes outside
of treatment, payment or health care operations, we will obtain
an authorization from you before releasing this information.
You
may revoke all such authorizations at any time, provided each revocation
is in writing. You may not revoke an authorization to the extent
that (1) we 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 with Neither Consent nor Authorization
We
may use or disclose PHI without your consent or authorization in
the following circumstances:
- Child
Abuse - If we have reasonable cause to believe that a child has
been abused, we must report that belief to the appropriate authority.
- Adult
and Domestic Abuse - If we have reasonable cause to believe that
a disabled adult or elder person has had a physical injury or
injuries inflicted upon such disabled adult or elder person, other
than by accidental means, or has been neglected or exploited,
we must report that belief to the appropriate authority.
- Health
Oversight Activities - If we are the subject of an inquiry by
the Georgia Board of Psychological Examiners, we may be required
to disclose protected health information regarding you in proceedings
before the Board.
- Judicial
and 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 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 we determine, or pursuant to the
standards of the profession should determine, that you present
a serious danger of violence to yourself or another, we may disclose
information in order to provide protection against such danger
for you or the intended victim.
- Worker's
Compensation - We 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 fault.
IV.
Patient's Rights and Psychologist'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.
However, we are 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 one of our professionals. On
your request, we will send your bills to another address.)
-
Right to Inspect and Copy - You have the right to inspect and/or
obtain a copy of PHI in our 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. We may deny your
request. On your request, we 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, we 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 the Beyond Words practice upon request, even if
you have agreed to receive the notice electronically.
Psychologist'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 communicate such
revisions with you either by mail or during session.
V.
Complaints
If
you are concerned that we have violated your privacy rights, or
you disagree with a decision we have made about access to your records,
you may contact Dr. Jeffrey Jones, Ph.D., 1762-B Century Blvd, Atlanta,
GA 30345, 404-633-3305.
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 April 2003.
We
reserve 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 by mail or in person during
a scheduled session.
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