T J Price, Psy D and Associates
NOTICE of PRIVACY RIGHTS
This Notice describes how medical and mental health information about you may be used and disclosed and how you can get access to the information. Please review it carefully.
During the process
of providing services to you, T J Price, Psy D and Associates will obtain,
record, and use mental health and medical information about you
that is protected health information. Ordinarily, that information is confidential and will not be used
or disclosed, except as described below.
* * * * Clients can obtain a full copy of this Notice
at our office. * * * *
I. USES AND DISCLOSURES OF PROTECTED INFORMATION
A. General
Uses and Disclosures Not Requiring the Client's Consent
The provider
will use and disclose protected health information in the following ways.
1.
Treatment
Treatment refers to the provision, coordination, or management of health
care [including mental health care] and related services by one or more
health care providers. For example, the provider will use your information
to plan your course of treatment. As to other examples, the provider
may consult with professional colleagues or ask professional colleagues
to cover calls or the practice for the provider and will provide the information
necessary to complete those tasks.
2.
Payment
Payment refers to the activities undertaken by a health care provider [including
a mental health provider] to obtain or provide reimbursement for the provision
of health care. The provider will use your information to develop
accounts receivable information, bill you, and with your consent, provide
information to your insurance company or other third party payer for services
provided. The information provided to insurers and other third party
payers may include information that identifies you, as well as your diagnosis,
type of service, date of service, provider name/identifier, and other information
about your condition and treatment. If you are covered by Medicaid,
information will be provided to the State of Colorado's Medicaid program,
including but not limited to your treatment, condition, diagnosis, and
services received.
3.
Health Care Operations
Health Care Operations refers to activities undertaken by the provider
that are regular functions of management and administrative activities
of the practice. For example, the provider may use or disclose your
health information in the monitoring of service quality, staff evaluation,
and obtaining legal services.
4.
Contacting the Client
The provider may contact you to remind you of appointments and to tell
you about treatments or other services that might be of benefit to you.
5.
Required by Law
The provider will disclose protected health care information when required
by law or necessary for health care oversight. This includes, but
is not limited to: (a) reporting child abuse or neglect; (b)
when court ordered to release information; (c) when there is a legal
duty to warn or take action regarding imminent danger to others;
(d) when the client is a danger to self or others or gravely disabled;
(e) when a coroner is investigating the client's death; or (f) to
health oversight agencies for oversight activities authorized by law and
necessary for the oversight of the health care system, government health
care programs, or regulatory compliance.
6.
Crimes on the premises or observed by the provider
Crimes that are observed by the provider or the provider's staff, crimes
that are directed toward the provider or the provider's staff, or crimes
that occur on the premises will be reported to law enforcement.
7.
Business Associates
Some of the functions of the provider may be provided by contracts with
business associates. For example, some of the billing, legal, auditing,
and practice management services may be provided by contracting with outside
entities to perform those services. In those situations, protected
health information will be provided to those contractors as is needed to
perform their contracted tasks. Business associates are required
to enter into an agreement maintaining the privacy of the protected health
information released to them.
8.
Research
The provider may use or disclose protected health information for research
purposes if the relevant limitations of the Federal HIPAA Privacy Regulation
are followed. 45 CFR # 164.512(i).
9.
Involuntary Clients
Information regarding clients who are being treated involuntarily, pursuant
to law, will be shared with other treatment providers, legal entities,
third party payers and others, as necessary to provide the care and management
coordination needed.
10.
Family Members
Except for certain minors, incompetent clients, or involuntary clients,
protected health information cannot be provided to family members without
the client's consent. In situations where family members are present
during a discussion with the client, and it can reasonably be inferred
from the circumstances that the client does not object, information may
be disclosed in the course of that discussion. However, if the client
objects, protected health information will not be disclosed.
11.
Emergencies
In life threatening emergencies the provider will disclose information
necessary to avoid serious harm or death.
B. Client
Authorization or Release of Information
The provider may not use or disclose protected information in any other
way without a signed authorization or release of information. When
you sign an authorization, or release of information, it may later be revoked,
provided that the revocation is in writing. The revocation will apply,
except to the extent the provider has already taken action in reliance
thereon.
II. YOUR RIGHTS AS A CLIENT
A. Access
to Protected Health Information
You have a right to inspect and obtain a copy of the protected health information
the provider has regarding you, in the designated record set. However,
you do not have the right to inspect or obtain a copy of psychotherapy
notes. There are other limitations to this right, which will be provided
to you at the time of your request, if any such limitation applies.
To make a request, ask your therapist.
B. Amendment
of Your Record
You have the right to request that the provider amend your protected health
information. The provider is not required to amend the record if
it is determined that the record is accurate and complete. There
are other exceptions, which will be provided to you at the time of your
request, if relevant, along with the appeal process available to you.
To make a request, ask your therapist.
C. Accounting
of Disclosures
You have the right to receive an accounting of certain disclosures the
provider has made regarding your health information. However, the
accounting does not include disclosures that were made for the purpose
of treatment, payment, or health care operations. In addition, the
accounting does not include disclosures made to you, disclosures made pursuant
to a signed Authorization, or disclosures made prior to April 14, 2003.
There are other exceptions that will be provided to you, should you request
an accounting. To make a request, ask your therapist.
D. Additional
Restrictions
You have the right to request additional restrictions on the use or disclosure
of your health information. The provider does not have to agree to
that request, and there are certain limits to any restriction, which will
be provided to you at the time of your request. To make a request,
ask your therapist.
E. Alternative
Means of Receiving Confidential Communications
You have the right to request that you receive communications of protected
health information from the provider by alternative means or at alternative
locations. For example, if you do not want the provider to mail bills
or other materials to your home, you can request that this information
be sent to another address. There are limitations to the granting
of such requests, which will be provided to you at the time of the request
process. To make a request, ask your therapist.
F. Copy
of This Notice
Clients have a right to obtain a copy of this Notice upon request.
III. ADDITIONAL INFORMATION
A. Privacy
Laws
The provider is required by State and Federal law to maintain the privacy
of protected health information. In addition, the provider is required
to provide clients with notice of the provider's legal duties and privacy
practices with respect to the protected health information. That
is the purpose of this Notice.
B. Terms
of the Notice and Changes to the Notice
The provider is required to abide by the terms of this Notice, or any amended
Notice that may follow. The provider reserves the right to change
the terms of its Notice and to make the new Notice provisions effective
for all protected health information that it maintains. When the
Notice is revised, the revised Notice will be posted at the provider's
service delivery sites and will be available upon request.
C. Complaints
Regarding Privacy Rights
If you believe the provider has violated your privacy rights, you have
the right to complain to the provider. Your therapist is the person
designated within this practice to receive your complaints. If that
does not resolve the matter, you may appeal to T J Price, Psy.D. directly.
You also have the right to complain to the United States Secretary of Health
and Human Services by sending your complaint to the Office of Civil Rights,
U.S. Department of Health and Human Services, 200 Independence Ave., S.W.
Room 515F, HHH Bldg., Washington, D.C. 20201. It is the policy of
the provider that there will be no retaliation for your filing of such
complaints.
D. Additional
Information
If you desire additional information about your privacy rights, ask your
therapist.
E. Effective
Date
April 14, 2003
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Office location:
777 S. Wadsworth Blvd, Bldg 2, Suite 103
Lakewood, CO 80226
303-202-6143
fax: 303-202-6146
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To send email directly to T J Price, click here: tj@Tjprice.com
Revised 1-17-08; TJ Price, PsyD