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.
PLEASE NOTE – The information about your matter is not confidential and is not protected by the doctor-patient privilege until and unless you become a patient of Westside Psychology Group PLLC’s practice. You should not send us any confidential information until we contact you, agree to provide care for you, and you execute a patient agreement. While we endeavor to check and answer all e-mail communications promptly, we make no guarantee of response to you within a fixed period of time.
We, the clinicians at Westside Psychology Group PLLC, may use or disclose your protected health information, for treatment, payment, and health care operations purposes. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“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.
“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 the 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 the office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure ” applies to activities outside of the office, such as releasing, transferring, or providing access to information about you to other parties.
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. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.
We will also need to obtain an authorization before releasing your psychotherapy notes (also referred to as electronic medical records, “EMR”). “Psychotherapy notes,” also known as “process notes,” are notes pertaining to an individual, group, or family therapy session that we have 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 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.
We may use or disclose PHI without your consent or authorization in the following circumstances:
Serious Threat to Health or Safety: If a clinician, in their professional capacity, has reasonable cause to suspect that you pose a serious threat of harm to yourself or another identified person, the clinician may contact local authorities and/or the threatened individual(s), as required by law. We may also contact your provided emergency contact to further ensure your health and safety.
Abuse of Child, Elder, or Dependent Adult: If a clinician, in their professional capacity, has reasonable cause to suspect that a child is being abused or maltreated, the clinician must report the information to the appropriate state or local protective services agency. A clinician may also report suspected abuse of an elder or dependent adult.
Health Oversight: If your clinician comes under investigation or audit, your relevant PHI may be provided to the New York Commissioner of Education.
Judicial or Administrative Proceedings: If we receive a court or administrative order, we will attempt to get your authorization before releasing your records, but are not required to do so.
Law Enforcement: We may provide information about you if you are involved in a crime that occurs on the office premises.
Workers’ Compensation: If you are being treated for issues involved with a workers’ compensation claim, then we may be required to provide relevant information from your record.
Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to request that certain PHI not be used or disclosed for treatment, payment, or health care operation purposes. We are not required to grant your request and may refuse to do so if we believe it would affect your health care.
Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
Right to Choose How Your PHI Is Sent to You: You have the right to ask to be contacted in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
Right to Inspect and Receive Copies of your PHI: You have the right to view and/or obtain a copy of your records. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within thirty (30) days of receiving your written request, and we may charge a reasonable, cost based fee for doing so. You do not have this right for psychotherapy notes (as defined in Section II).
Right to List of Disclosures Made: You have the right to request a list of instances in which your PHI was disclosed for purposes other than treatment, payment, or health care operations, or for which you provided an Authorization. We will respond to your request for an accounting of disclosures within sixty (60) days of receiving your request. The list will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we charge you a reasonable cost based fee for each additional request.
Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may deny your request, but will explain the denial in writing within sixty (60) days of receiving your request.
Right to a Paper or Electronic Copy of this Notice: You have the right to obtain a paper copy and/or electronic copy of this notice at your request.
Rights Under the “No Surprise Act”: If you are not using insurance for therapy or you are uninsured, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Psychologist’s Duties: We are required by law to maintain the privacy of your PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, please contact us at email@example.com or 212-519-7594 to discuss these matters.
If you believe that your privacy rights have been violated and wish to file a complaint, you may contact New York’s Professional Misconduct Enforcement System at 1-800-442-8106 or firstname.lastname@example.org. You may also address your complaints to the Secretary of the US Department of Health and Human Services by visiting the website www.hhs.gov/hipaa/filing-a-complaint/index.html.
We will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on June 1, 2023. 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 either distributing it to you in the office or sending it to your email address.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing a HIPAA receipt form, you are acknowledging that you have received a copy of our Notice of Privacy Practices, and have read, understood, and agreed to the items contained therein.