Psychological Resources, Ltd.
OHIO NOTICE FORM
Notice of 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. Your therapist may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. These terms are defined in the available full text version of this notice. A complete version of this notice is posted on our website: http://www.psychresources.com.
II Uses and Disclosures Requiring Authorization:
If you authorize it in writing, your therapist can use or disclose protected health care information beyond that indicated in Section I. Your authorization is required to release psychotherapy notes, something kept separate from your medical record. These notes are given more protection than other information. You can revoke any authorization at any time in writing. Your therapist will also obtain an authorization from you before using or disclosing PHI in a way not descried in this Notice or for marketing purposes.
III. Uses and Disclosures without Consent or Authorization:
Your therapist may use or disclose PHI without your consent in the following circumstances: suspected child abuse, suspected elder abuse, court-ordered release of information, suspected serious threat to the health or safety of yourself or others, and if you file a Workers Compensation claim. Your therapist may use or disclose PHI when the use or disclosure without your consent or authorization is allowed under other Sections of 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for duty, eligibility for VA benefits, and national security and intelligence.
IV. Patient’s Rights and your Therapist’s Duties:
1) You can request restrictions regarding your PHI,
2) you can have communications by alternate means or alternate locations,
3) you can inspect or obtain a copy of your PHI,
4) you have the right to request amendment of your PHI,
5) you can get an accounting of disclosures of PHI,
6) you have the right to a paper copy of the complete notice that is summarized on this page.
7) you have the right to restrict disclosure of PHI to a health plan when you pay out-of-pocket in full for services.
8) you have the right to be notified if
(a) there is a breach involving your PHI;
(b) PHI has not been encrypted to government standards; and
(c) risk assessment fails to determine there is a low probability your PHI has been compromised.
Your therapist is required to keep your PHI private and provide you with a notice of the legal duties and privacy practices regarding your PHI. Your therapist has the right to change privacy policies but will notify you when this happens.
If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision your therapist made about access to your records, you may contact Ms. Lynn Spencer, HIPAA Compliance Officer, at 419.475.2535. You can also contact the U.S. Department of Health and Human Services.
This notice will go into effect on April 14, 2003. Your therapist has the right to change the terms of this notice, but will provide you with a revised notice.
VII. General Consent and Claims Payment Authorization:
I consent to allow Psychological Resources, Ltd. to disclose my PHI for purposes of treatment, payment and health care operations. I consent to have my insurer assign benefits to my provider. I understand payment for services is ultimately my responsibility. I understand co-payments are due at the time of service. I understand if I have no insurance coverage, payment is due at the time of service. If I am a divorced parent seeking services for my child, I understand I am responsible for paying for services. I understand I may be charged for missed appointments not canceled 24 hours in advance. I understand confidentiality may be suspended if collection procedures are instituted for my account.
We hope this policy allows us to provide quality care for our clients. Information about specific charges for specific services is available upon request. If you have any questions, need clarification about our policy or if a problem arises regarding your account, please do not hesitate to contact our office.
Psychological Resources, Ltd. 06/24/2014
Psychological Resources, Ltd. reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. Psychological Resources, Ltd. will provide you with a revised notice by posting in the reception area or, if you are an inactive patient, by mail.