and Practices to Protect the Privacy of Your Health Information
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.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
Psychological Services may use
information (PHI), for treatment,
health care operations
purposes with your consent.
To help clarify these terms, here are some definitions:
"PHI" refers to information in your
that could identify you.
"Treatment, Payment and
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 Susquehanna Psychological Services.
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
Psychological Services such as sharing, employing, applying, utilizing,
examining, and analyzing information that identifies you.
"Disclosure" applies to activities outside of
Psychological Services, such as releasing, transferring, or providing
access to information about you to other parties.
Uses and Disclosures Requiring Authorization
Uses and Disclosures with Neither Consent nor Authorization
Services 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 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. We will also need to obtain an
authorization before releasing your psychotherapy notes.
are notes your therapist has made about your conversation during a
private, group, joint, or family counseling session, which 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 or psychotherapy notes) 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.
Services may use or disclose PHI without your consent or authorization
in the following circumstances:
If your therapist has
reasonable cause, on the basis of their professional judgment, to
suspect abuse of children with whom they come into contact in their
professional capacity, they are required by law to report this to the
Pennsylvania Department of Public Welfare.
and Domestic Abuse: If your
therapist has reasonable cause to believe that an older adult is in
need of protective services (regarding abuse, neglect, exploitation or
abandonment), they may report such to the local agency which provides
or Administrative Proceedings:
If you are involved in a court proceeding and a request is made about
the professional services provided to you at Stauffer Psychological
Services or the records thereof, such information is privileged under
state law, and we will not release the 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.
Threat to Health or Safety: If
you express a serious threat, or intent to kill or seriously injure an
identified or readily identifiable person or group of people, and your
therapist determines that you are likely to carry out the threat, they
must take reasonable measures to prevent harm. Reasonable measures may
include directly advising the potential victim of the threat or intent.
If you file a
worker's compensation claim, your therapist will be required to file
periodic reports with your employer which shall include, where
pertinent, history, diagnosis, treatment, and prognosis.
Patient's Rights and Psychologist's Duties
to Request Restrictions - You
have the right to request restrictions on certain uses and disclosures
of protected health information about you. However, Susquehanna
Psychological Services is not required to agree to a restriction you
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 a
therapist. Upon your request, we will send your bills to another
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. Susquehanna Psychological
Services may deny your access to PHI under certain circumstances, but
in some cases, you may have this decision reviewed. On your request,
your therapist will discuss with you the details of the request and
to Amend -
You have the
right to request an amendment of PHI for as long as the PHI is
maintained in the record. Susquehanna Psychological Services may deny your
request. On your request, your therapist will discuss with you the
details of the amendment process.
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, your
therapist will discuss with you the details of the accounting process.
to a Paper Copy
- You have
the right to obtain a paper copy of the notice from Susquehanna
Psychological Services upon request, even if you have agreed to receive
the notice electronically.
Susquehanna Psychological Services
is required by law to maintain the privacy of PHI and to provide you
with a notice of our legal duties and privacy practices with respect to
Susquehanna Psychological Services
reserves the right to change the privacy policies and practices
described in this notice. Unless we notify you of such changes,
however, we are required to abide by the terms currently in effect.
we revise our policies and procedures, Susquehanna Psychological Services
will send you a copy by mail or give it to you in person when you come
for your session.
If you are concerned that Susquehanna
Psychological Services has violated your privacy rights, or you
disagree with a decision made about access to your records, you may
contact Cynthia Stauffer, Licensed Psychologist at 717-579-6715. 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.
This Notice is effective