HIPAA Disclosure . . . . . .
Psychologists' Policies and Practices to Protect the Privacy of Your
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.
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
refers to information in your health record that could identify you.
"Treatment, Payment and Health Care Operations"
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.
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
- 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
applies only to activities within my [office, clinic, practice group,
etc.] such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you.
applies to activities outside of my [office, clinic, practice group,
etc.], 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
I may use or
disclose PHI without your consent or authorization in the following
Child Abuse: If I have reasonable cause to believe that a child has
suffered abuse or neglect, I am required by law to report it to the
proper law enforcement agency or the Washington Department of Social and
Adult and Domestic Abuse: If I have reasonable cause to believe that
abandonment, abuse, financial exploitation, or neglect of a vulnerable
adult has occurred, I must immediately report the abuse to the
Washington Department of Social and Health Services. If I have reason to
suspect that sexual or physical assault has occurred, I must immediately
report to the appropriate law enforcement agency and to the Department
of Social and Health Services.
Health Oversight: If the Washington Examining Board of Psychology
subpoenas me as part of its investigations, hearings or proceedings
relating to the discipline, issuance or denial of licensure of state
licensed psychologists, I must comply with its orders. This could
include disclosing your relevant mental health information.
Judicial or Administrative Proceedings: If you are involved in a court
proceeding and a request is made for information about the professional
services that I have provided to you and the records thereof, such
information is privileged under state law, and I will not release
information without the written authorization of you or your legal
representative, or a subpoena of which you have been properly notified
and you have failed to inform me that you are opposing the subpoena, 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:
I may disclose your
confidential mental health information to any person without
authorization if I reasonably believe that disclosure will avoid or
minimize imminent danger to your health or safety, or the health or
safety of any other individual.
Worker's Compensation: If you file a worker's compensation claim, with
certain exceptions, I
must make available, at any stage of the proceedings,
all mental health information in my possession relevant to that
particular injury in the opinion of the Washington Department of Labor
and Industries, to your employer, your representative, and the
Department of Labor and Industries upon request.
IV. Patient's Rights and Psychologist's Duties
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 and psychotherapy
notes 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 for which you have neither provided consent nor authorization (as
described in Section III of this Notice). 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.
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.
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.
revise my policies and procedures, I will date and post a copy of the
V. Questions and
If you have
questions about this notice, disagree with a decision I make about
access to your records, or have other concerns about your privacy
rights, you may contact me, Renee Gilbert, Ph.D. at (425) 455-5400.
If you believe
that your privacy rights have been violated and wish to file a complaint
with me/my office, you may send your written notice of your
complaint to me, Renee Gilbert, Ph.D. at 40 Lake Bellevue, Suite 100,
Bellevue, Washington 98005.
You may also send
a written complaint to the Secretary of the U.S. Department of Health
and Human Services. I will be happy to provide you with the
appropriate address upon request.
You have specific
rights under the Privacy Rule. I will not retaliate against you for
exercising your right to file a complaint.
This notice will
go into effect on August 1, 2005.
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. Revisions to this
notice will be posted to this website at the time of revision. I will be
happy to provide you with a written copy of these revisions upon