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Wisconsin
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.
Uses and Disclosures for
Treatment, Payment, and Health Care Operations
We 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 we provide, coordinate or manage your health care and other
services related to your health care. An example of treatment would be when
we consult with another health care provider, such as your family physician
or another psychologist/therapist.
Payment is when we obtain reimbursement for your healthcare. Examples of
payment are 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 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 our clinic such
as sharing, employing, applying, utilizing, examining, and analyzing information
that identifies you.
“Disclosure” applies to activities
outside of our clinic, such as releasing, transferring, or providing
access to information about
you
to other parties.
Uses and Disclosures Requiring Authorization
We 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 we are asked
for information for purposes
outside of treatment, payment and health care operations, we will
obtain an authorization from you before releasing this information.
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) we 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.
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 suspect that a child seen in
the course of our professional duties has been abused or neglected, or
have reason
to believe that a child seen in the course of our professional duties has
been threatened with abuse or neglect, and that abuse or neglect of the
child will
occur, we must report this to the relevant county department, child welfare
agency, police, or sheriff’s department.
Adult and Domestic Abuse: If we believe that an elder person has been abused,
or neglected, we may report such information to the relevant county department
or state official of the long-term care ombudsman.
Health Oversight: If the Wisconsin Department of Regulation and Licensing requests
that we release records to them in order for the Examining Board to investigate
a complaint, we must comply with such a request.
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 we
will not release the information without written authorization from you or
your personal 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. You will be informed in advance, if this is the
case.
Serious Threat to Health or Safety: If we have reason to believe, exercising
our professional care and skill, that you may cause harm to yourself or another,
we must warn the third party and/or take steps to protect you, which may include
instituting commitment proceedings.
Worker’s Compensation: If you file a worker's compensation claim, I
may be required to release records relevant to that claim to your employer
or its
insurer and we may be required to testify.
Patient's Rights and Psychologist/Therapist’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 about you.
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 us. Upon your request,
we 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 our mental health and billing records used to make
decisions about you for as long as the PHI is maintained in the record. On
your request, we will discuss with you the details of the request 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 regarding you. 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 us upon request, even if you have agreed to receive the notice
electronically.
Psychologist/Therapist’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 post changes at the clinic.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree
with a decision we made about access to your records, you may contact Gregg
Brewer, MS, at 907-8201.
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.
Effective Date, Restrictions and Changes to Privacy
Policy
This notice went into effect on April 14, 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 post a revised
notice in the clinic.
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Doll & Associates, S.C.
40 Camelot Drive
Fond du Lac, WI 54935
Phone (920) 907-8201
Fax (920) 907-8209
1567 Sumner Street, Suite 201
Hartford, WI 53027
Phone (877) 907-8201
info@dollandassociates.com |
