The Network of Independent Practioners at InSight Counseling, LLC take the importance of your privacy very seriously. Please read this form carefully and feel free to ask your clinician any questions regarding your rights.
HIPAA, the Health Insurance Portability and Accountability Act of 1996, requires this notice under federal law, setting the standards held by health care providers across the nation. This notice explains how your clinician handles your Personal Health Information (PHI) and how your can see and amend your information. If a standard in Kansas law conflicts with a standard in the HIPAA privacy rule, your health care provider must follow the law that is the most protective of your rights. “Use” is when your clinician or those under the clinician’s direction, read, share, utilize and analyze your information in the office. “Disclosure” is when information is shared with others outside the office.
Your Personal Health Information (PHI) includes information collected about you and your health. It includes your health and treatment history, present health status, and prognosis. Specifics may include: your diagnosis, symptoms, complaints, treatment plan and goals, progress towards these goals, records to and from other health care providers, laboratory tests, billing records, and demographic information.
Your clinician may use and disclosure your Personal Health Information without your consent for Treatment, Payment, and Health Care Operations (“TPO”). Your clinician will keep disclosure of PHI to a minimum of what is reasonably necessary to accomplish the intended purpose when an authorization is not required.
Treatment is providing, coordinating or managing your health care and other services related to your health care. Examples include consulting with another health care provider, updating your family physician, or, when referring, updating the clinician about your treatment.
Payment is obtaining reimbursement for your healthcare. Examples include disclosing your PHI to your health insurer to obtain reimbursement for your health care or if you fail to pay your account, your identity and the amounts that you owe may be given to a collection agency.
Health Care Operations are activities that relate to the performance and operation of the health provider’s practice. Examples include case management, messages left for appointment reminders or rescheduling (unless alternative method is requested), and outsourcing to other businesses for tasks such as copying, shredding, or billing. To protect your privacy, the business associates have contracted to safeguard your information. Your PHI may be used to contact you in order to recommend possible treatments or alternative health-related services that may be of interest to you. In addition, your PHI may be used or disclosed without releasing your identity in order to research treatments. If there is a need to disclose your identity, the research project will be discussed with you and, if you approve, you may sign a special Authorization form before identifying information is shared. Your PHI may also be used to conduct training programs for students, trainees, or practioners in areas of health care to learn under supervision to practice and improve their skills as providers.
Your clinician may not use or disclose your Personal Health Information for purposes outside of TPO without your written Authorization of Release of Information.
An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.
In addition, we will need an authorization releasing your psychotherapy notes. “Psychotherapy Notes” are notes made by your clinician about the conversation during a private, group, joint, or family counseling session and have been 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 if 1) Your clinician 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.
Your clinician may use or disclose your PHI without your consent or authorization in the following circumstances:
Child Abuse – If your clinician has reasonable cause to suspect that a child has been or may be subjected to abuse or neglect, or if a child is observed by your clinician being subjected to conditions which would reasonably result in abuse or neglect, the clinician MUST immediately report such information to the appropriate authorities as required by law.
Adult and Domestic Abuse – If your clinician has reasonable cause to suspect that an eligible adult (defined below) presents a likelihood of suffering physical harm or is in need of protective services, the clinician must report such information to the appropriate authorities as required by law. “Eligible adult” means any person 60 years of age or older, or an adult with a handicap (substantially limiting mental or physical impairment) between the ages of 18 and 59 who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs.
Health Oversight Activities – Your clinician may disclose PHI to the Kansas Behavioral Sciences Regulatory Board if necessary for proceeding before the Board.
Judicial and Administrative Proceedings – If you are involved in a court proceeding and request is made for information about your diagnosis or treatment and the records thereof, such information is privilege under state law, and your clinician will not release information without written authorization from you or your persona or 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. Your clinician will inform you in advance if this is the case.
Serious Threat to health or Safety – When your clinician judges that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by you on yourself or another person, your clinician may disclose your relevant confidential information to the appropriate professional workers, public authorities, the potential victim, his or her family, or your family in order to protect you or the individual threatened.
Law enforcement – Your clinician may disclose your PHI under certain circumstances to law enforcement officials investigating a crime.
Specific government Functions – Your clinician may disclose your PHI to military personnel and veterans, to government benefit programs relating to eligibility and enrollment, Workers Compensation programs, to correctional facilities if you are an inmate, and for national security reasons.
Patient’s Rights and Clinician’s Duties
Right to request restrictions – You can request restrictions on certain uses and disclosures of protected health information. However, your clinician is not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means 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 a family member to know that you are seeing your clinician. You can request your bills be sent to another address.)
Right to Inspect and Copy – Although your PHI is the physical property of your clinician, you have the right to inspect or obtain a copy (or both) of your PHI and billing records as long as the PHI is maintained in the record. There may be a cost for this service. Your clinician may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. Upon request, your clinician 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 clinician may deny your request. Upon your request, your clinician 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. The accounting includes what was disclosed, when it was disseminated, and the person/agency that received the information.
Right to a Paper Copy – You have a write to obtain a paper copy of the notice from your clinician upon request, even if you have agreed to receive the notice electronically.
- To maintain the privacy of PHI as described in this Notice.
- To provide you with a Notice of legal duties and privacy practices with respect to PHI no later than the first date of service.
- To obtain confirmation you received this Notice.
- To post this Notice in the office and on the website so everyone can see it.
If you have questions or problems please speak with your clinician (Privacy Officer) at 913-631-3800. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact your clinician to file a complaint. You can also file a complaint with the Office for Civil rights, Health and Human Services (OCR) at http://www.hhs.gov/ocr/privacyhowtofile.htm. You can call OCR toll-free at 1-800-368-1019 if you need help in filing a complaint. The regional OCR office is at 816-426-7278 in Kansas City, MO. You have the right to file a complaint about your clinician by contacting the Kansas Behavioral Sciences Regulatory Board (KSRB) at 785-296-3240. The Board of Healing Arts provides a list of boards that regulate other health care professionals at http://www.ksbha.org/contacts.html. Filling a complaint will not result in a limitation of care.
The Clinician reserves the right to revise this Notice and make the new provisions effective for all PHI that your clinician maintains. The revised Notice will be posted in the office and on the website (insightkc.org). You or anyone else may obtain a copy at any time.
This Notice will go into effect April 27, 2009.