I. Introduction to Clients

This notice will tell you about how I handle information about you and your child. It tells how I use this information in my office, how I share it with other professionals and organizations, and how you can see it. I am required to tell you about this because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In most situations I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by state law or HIPAA. Clients who are 13 or older must sign the written authorization form.

II. Your Medical Information

Each time you or your child visit me, information is collected about your or your child’s physical or mental health. It may be information about you or your child’s past, present or future health or condition, the treatment or services received, or about payment for health care. This information is called PHI, which stands for Protected Health Information. The information I obtain from you or your child goes into your or your child’s medical record at my office.My records may be computerized or written and stored in paper files. Files are likely to include the following:

• Your or your child’s personal history
• Reasons you or your child came for treatment: problems, symptoms, needs, goals
• Diagnoses: medical terms for your or your child’s problems, symptoms, disabilities
• Treatment Plan: services that I think will help you or your child
• Progress Notes
• Records from others who treated or evaluated you or your child
• Psychological test scores, school records, and the like
• Information about medications you or your child are taking
• Legal matters
• Billing and insurance information

This information is used for many purposes. For example I may use it to:

• Plan your or your child’s care
• Decide how well my treatment is working for you or your child
• Talk with other health care professionals who are also treating you or your child, such as your family doctor or a professional who referred you to me
• Show that you actually received the services from me that I billed to you or your health insurance company

Because the records are of a professional and technical nature, they can be misinterpreted or prove to be upsetting to an untrained reader. For this reason I recommend that you initially review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. In most situations I am allowed to charge a reasonable fee for copying those records. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request. In the event that I become incapacitated, psychologist Fredric Provenzano, Ph.D. will become custodian of my records and will assume their management. His office phone number is (206) 361-2343.

If you find anything in the records that you think is incorrect or something important is missing, you may ask me to amend (add information to) your record. In some rare situations, I do not have to agree to that.

III. How Protected Health Information Can Be Used and Shared

When your or your child’s information is read by me or others in my office, it is called “use.” If the information is shared with or sent to others outside this office, it is called “disclosure.” Except in some special circumstances, when I use your or your child’s PHI or disclose it to others, I share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed.

IV. Uses and Disclosures of PHI in Health Care with Your Consent

I need information about you or your child in order to provide satisfactory treatment and evaluative services for you. It is necessary that I collect that information, use it, and share it as necessary. Therefore, you must sign the Client Services Agreement before I begin to provide services for you or your child. If you do not give your consent, I cannot treat or evaluate you or your child. Generally, I may use or disclose your or your child’s PHI for three purposes: treatment, obtaining payment and communicating with third party payors about payment, and what are termed health care operations. If I have assistants helping with my practice, they will follow the same legal guidelines.

Treatment. I might use your medical information to provide you or your child with psychological services or treatment. These might include individual, family, or group therapy, psychological or educational testing, treatment planning, or measuring the effects of my services.

I might share or disclose your or your child’s PHI to others who provide treatment to you or your child, including your personal physician. I may occasionally find it helpful to consult other health and mental health professionals about a case. If I consult with a professional who is not involved in your treatment, I make every effort to avoid revealing your identity. These professionals are legally bound to keep the information confidential.

I may refer you or your child to other professionals or consultants for services that I cannot or choose not to offer, such as special testing or treatments. When I do this, I need to tell those people things about your and your child’s conditions.

I may leave a message for you regarding an appointment. Please fill out the "Authorization to Leave Personal Health Information by Alternate Means" so that I may comply with your wishes. If you want me to call you only at work or at home, I can usually arrange for that. I often leave messages on home answering machines. If this creates a problem, please let me know. I use cell and cordless phones, so privacy cannot be absolutely guaranteed with these devices.

Payment. I may use your information to bill you, your insurance, or others in order to be paid for the evaluation and treatment I provide to you or your child. I may contact your insurance company to determine what your insurance covers. I may have to tell them your or your child’s diagnoses, dates of service, and what treatments you have received.

Health Care Operations. There are some other ways I may use or disclose your PHI, which are called health care operations. For example, I may be required to supply information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If I do, your or your child’s name and identity will be removed from what I send.

Business associates may assist me with tasks like billing, filing, and taking messages. These assistants need to receive some of your or your child’s PHI to perform these services properly. To protect your privacy, they will safeguard your and your child’s information.

V. Uses and Disclosures Requiring Your Authorization

If I want to use your or your child’s PHI for any purpose besides those described above, I need your written permission on an authorization form. If you do authorize me to use or disclose your or your child’s PHI, you can revoke that permission in writing at any time but this will not affect any use or disclosure made by me before the disclosure. If you want me to share information about you or your child with your family or close others, I will ask you what information you want me to share and with whom.

VI. Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent or Authorization

If you are involved in a court proceeding and a request is made for information concerning the professional services I provided you, such information may be protected by the law. I cannot provide any information without your written authorization or a court order requiring the disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely court disclosures.

If a governmental agency requests your or your child’s PHI for health oversight activities, I may be required to provide it to them. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. If a patient files a worker’s compensation claim and the services I am providing are relevant to the injury for which the claim was made, I must, upon appropriate request, provide a copy of the patient’s record to the patient’s employer and the Department of Labor and Industries.

In some situations I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual.

If I have reasonable cause to believe that a child has suffered abuse or neglect, the law requires me to file a report with the appropriate government agency, usually the Department of Social and Health Services. Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires me to file a report with the appropriate government agency, usually the Department of Social and Health Services. Once such a report is filed, I may be required to provide additional information. If I reasonably believe that there is imminent danger to the health or safety of the patient or any other individual, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can help provide protection.

If such a situation arises, I will make every effort to discuss it fully with you before taking any action. I will limit my disclosure to what is necessary.

While this summary of exceptions to confidentiality should help inform you about potential problems, it is important that we discuss any questions or concerns that you now have or develop in the future. The law governing confidentiality can be complex. In situations where specific advice is required, you may need formal legal advice.

VII. Patient Rights

In summary, HIPAA and Washington State law provide you with certain rights regarding your clinical record and disclosure of protected health information about you. These rights include:

• requesting that I amend your record
• requesting restrictions on what information from your clinical record is disclosed to others
• requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized
• determining the location to which protected information disclosures are sent
• having any complaints you make about my policies and procedures recorded in your records
• receipt of a copy of this Notice of Privacy Practices form

VIII. Exclusions from Disclosure Involving Minor Children

If I am to provide therapy or testing services for your minor child, you generally have the right to inspect and copy (within certain limitations and after payment of a reasonable fee) my records used by me to make decisions about your minor child. Two primary exceptions apply to this right to inspect and copy:

• Notes containing statements made by your minor child in therapy sessions are protected by the child's right to confidentiality. They will not be disclosed or released to you unless required by law or unless I decide that disclosure is in the best interests of the child.
• Test data (other than test results) and materials are protected by the owners and publishers of standardized psychoeducational, behavioral, and academic tests. Disclosure by me of the raw data and materials to anyone other than a licensed professional qualified to interpret the data is prohibited.

IX. An Accounting of Disclosures

When I disclose your or your child’s PHI, I will keep a record of what was sent, when I sent it and to whom it was sent. You may ask for it at any time.

If you need more information or have questions about these privacy practices, please ask me. If you have a problem with how your or your child’s PHI has been handled, or if you believe your or your child’s privacy rights have been violated, please let me know. You have the right to file a complaint with me and with the Secretary of the Federal Department of Health and Human Services. I will not in any way limit your or your child’s care or take any actions against you if you complain. I am the designated privacy officer for my practice and can be reached by phone at (206) 465-8068.

Belle Chenault, Ph.D.