to Confidentiality l Patient
Rights l Privacy Document
Confidentiality: Information about your coming to
therapy, and what you share is private, and can not
be released without your permission. There are a few
exceptions to confidentiality, that apply to all
Licensed Health Care Providers in the State of
Psychologists’ Policies and Practices to Protect the
Privacy of Your Health Information
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
I. Uses and
Disclosures for Treatment, Payment, and Health Care
I 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.
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 psychologist.
- “Treatment, Payment and Health Care
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.
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
“Use” applies only
to activities within my office, such as sharing,
employing, applying, utilizing, examining, and
analyzing information that identifies you.
to activities outside of my office, such as releasing,
transferring, or providing access to information about
you to other parties.
and Disclosures Requiring Authorization
I 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 I am asked
for information for purposes outside of treatment,
payment and health care operations, I will obtain an
authorization from you before releasing this
information. I will also need to obtain an
authorization before releasing your psychotherapy
notes. “Psychotherapy notes” are notes I have made
about our conversation during a private, group, joint,
or family counseling session, which I have kept
separate from the rest of your medical record.
These notes are given a greater degree of protection
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)
I 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.
and Disclosures with Neither Consent nor Authorization
I may use or
disclose PHI without your consent or authorization in
the following circumstances:
- Child Abuse: If I, in my professional
capacity, have reasonable cause to believe that a
minor child is suffering physical or emotional
injury resulting from abuse inflicted upon him or
her which causes harm or substantial risk of harm to
the child's health or welfare (including sexual
abuse), or from neglect, including malnutrition, I
must immediately report such condition to the
Massachusetts Department of Social Services.
- Adult and Domestic Abuse: If I have
reasonable cause to believe that an elderly person
(age 60 or older) is suffering from or has died as a
result of abuse, I must immediately make a report to
the Massachusetts Department of Elder Affairs.
- Health Oversight: The Board of Registration
of Psychologists has the power, when necessary, to
subpoena relevant records should I be the focus of
- 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 I will not release
information without written authorization from you
or your 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 you
communicate to me an explicit threat to kill or
inflict serious bodily injury upon an identified
person and you have the apparent intent and ability
to carry out the threat, I must take reasonable
precautions. Reasonable precautions may
include warning the potential victim, notifying law
enforcement, or arranging for your
hospitalization. I must also do so if I know
you have a history of physical violence and I
believe there is a clear and present danger that you
will attempt to kill or inflict bodily injury upon
an identified person. Furthermore, if you
present a clear and present danger to yourself and
refuse to accept further appropriate treatment, and
I have a reasonable basis to believe that you can be
committed to a hospital, I must seek said commitment
and may contact members of your family or other
individuals if it would assist in protecting you.
- Worker’s Compensation: If you file a workers’
compensation claim, your records relevant to that
claim will not be confidential to entities such as
your employer, the insurer and the Division of
Rights and Psychologist's Duties
- Right to Request Restrictions – You have the
right to request restrictions on certain uses and
disclosures of protected health information about
you. 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. Upon 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
and psychotherapy notes 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
- 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 for which you have neither provided consent nor
authorization (as described in Section III of this
Notice). 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
- 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.
- I reserve the right to change the privacy
policies and practices described in this notice.
Unless I notify you of such changes, however, I am
required to abide by the terms currently in effect.
- If I revise my policies and procedures, I
will mail you a copy of any revisions.
If you are concerned
that I have violated your privacy rights, or you
disagree with a decision I made about access to your
records, you may contact me to discuss it.
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,
This notice will go
into effect on 4/14/2003
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. I will provide you with a revised
notice by mail.