Notice of Psychologists’ Policies and Practices to Protect the Privacy of

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:

• “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.

• “Use” applies only to activities within my [office, clinic, practice group, etc.] such as

sharing, employing, applying, utilizing, examining, and analyzing information that

identifies you.

• “Disclosure” 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 Authorization

I may use or disclose PHI without your consent or authorization in the following

circumstances:

• Child Abuse: If, in my professional capacity, a child comes before me which I have

reasonable cause to suspect is an abused or maltreated child, or I have reasonable

cause to suspect a child is abused or maltreated where the parent, guardian, custodian

or other person legally responsible for such child comes before me in my professional

or official capacity and states from personal knowledge facts, conditions or

circumstances which, if correct, would render the child an abused or maltreated child,

I must report such abuse or maltreatment to the statewide central register of child

abuse and maltreatment, or the local child protective services agency.

􀂃 Health Oversight: If there is an inquiry or complaint about my professional conduct

to the Arizona State Board for Psychology, I must furnish to the New York

Commissioner of Education, your confidential mental health records relevant to this

inquiry.

• 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 you and/or the records thereof, such information is privileged under state

law, and I must not release this information without your written authorization, or a

court order. This privilege does not apply when you are being evaluated for a third

party or where the evaluation is court ordered. I must inform you in advance if this is

the case.

• Serious Threat to Health or Safety: I may disclose your confidential information to

protect you or others from a serious threat of harm by you.

􀂃 Worker’s Compensation: If you file a worker’s compensation claim, and I am

treating you for the issues involved with that complaint, then I must furnish to the

chairman of the Worker’s Compensation Board records which contain information

regarding your psychological condition and treatment.

IV. Patient's Rights and Psychologist's Duties

Patient’s Rights:

• 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.

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 mail the revised Notice to you, as well

as making it available in my office.

V. Questions and Complaints

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 Steve Drydyk, Ph.D.;3651 E. Baseline Road; Gilbert, Arizona 85234.

If you believe that your privacy rights have been violated and wish to file a complaint

with me, you may send your written complaint to Steve Drydyk, Ph.D.;3651 E. Baseline Road; Gilbert, Arizona 85234.

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.

You have specific rights under the Privacy Rule. I will not retaliate against you for

exercising your right to file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on 1/1/20051

NEW YORK NOTICE FORM