03/18/2003
SOUTH CAROLINA 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.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
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:
"Use" applies only to activities within my practice such as sharing,
employing, applying, utilizing, examining, and analyzing information that
identifies you.
"PHI" refers to information in your health record that could identify you.
"Treatment, Payment and Health Care Operations" Treatment
is 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.
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.
Health Care 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
coordination.
"Disclosure" applies to activities outside of my practice, such as
releasing, transferring, or providing access to information about you to other
parties.
II. Uses 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 than PHI.
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.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the
following circumstances:
Child Abuse: When in my professional capacity, I have received
information which gives me reason to believe that a child's physical or mental
health or welfare has been or may be adversely affected by abuse or neglect, I
must report such to the county Department of Social Services, or to a law
enforcement agency in the county where the child resides or is found. If I
have received information in my professional capacity which gives me reason to
believe that a child's physical or mental health or welfare has been or may be
adversely affected by acts or omissions that would be child abuse or neglect
if committed by a parent, guardian, or other person responsible for the
child's welfare, but I believe that the act or omission was committed by a
person other than the parent, guardian, or other person responsible for the
child's welfare, I must make a report to the appropriate law enforcement
agency.
Adult and Domestic Abuse: If I have reason to believe that a vulnerable
adult has been or is likely to be abused, neglected, or exploited, I must
report the incident within 24 hours or the next business day to the Adult
Protective Services Program. I may also report directly to law enforcement
personnel.
Health Oversight: The South Carolina Board of Examiners in
Psychology has the power, if necessary, to
subpoena my records. I am then required to submit to them those records
relevant to their inquiry.
Judicial or administrative proceedings: If you are involved in a court
proceeding and a request is made about the professional services I provided
you or the records thereof, such information is privileged under state law,
and I will not release information without your written consent 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 the
intention to commit a crime or harm yourself, I may disclose confidential
information when I judge that disclosure is necessary to protect against a
clear and substantial risk of imminent serious harm being inflicted by you on
yourself or another person. In this situation, I must limit disclosure of the
otherwise confidential information to only those persons and only that content
which would be consistent with the standards of the profession in addressing
such problems.
Workers' Compensation: If you file a workers’ compensation claim, I am
required by law to provide all existing information compiled by me pertaining
to the claim to your employer, the insurance carrier, their attorneys, the
South Carolina Worker’s Compensation Commission, or you.
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 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 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. 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 regarding you. 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
notice electronically
Psychologist’s Duties:
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 notify you in writing by
mail or in person.
V. Complaints
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
at 1173 Southgate Drive Suite A Charleston, SC 29407 or 843-571-4005.
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, Restrictions and Changes to Privacy Policy
This notice will go into effect on March 18, 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 giving it to you in person or through US Mail.
