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Privacy
Notice
MASSACHUSETTS
NOTICE FORM
Notice of Mental
Health Professional’s 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 mental health professional.
- 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 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 the 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 I, in my professional capacity, have reason to believe that a
minor child is suffering physical or emotional injury resulting
from abuse inflicted upon him or her which causes harm or substantial
risk of harm to the child’s health or welfare (including sexual
abuse), or from neglect, including malnutrition, I must immediately
report such a condition to the Massachusetts Department of Social
Services.
-
Adult and
Domestic Abuse: If I have reasonable cause to believe that an
elderly person (age 60 or older) is suffering from or has died as
a result of abuse, I must immediately make a report to the Massachusetts
Department of Elder Affairs.
-
Health Oversight:
The Board of Registration of each mental health profession has the
power, when necessary, to subpoena relevant records should I be
the focus of an inquiry.
-
Judicial
or Administrative Proceedings: If you are involved in a court
proceeding and a request is made for information about your diagnosis
and treatment and the records thereof, such information is privileged
under state law and I will not release information without written
authorization from you or your legally appointed representative,
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 an explicit threat
to kill or inflict serious bodily injury upon an identified person
and you have the apparent intent and ability to carry out the threat,
I must take reasonable precautions. Reasonable precautions may include
warning the potential victim, notifying law enforcement, or arranging
for your hospitalization. I must also do so if I know you have a
history of physical violence and I believe there is a clear and
present danger that you will attempt to kill or inflict bodily injury
upon an identified person.
Furthermore, if you present a clear and present danger to yourself
and refuse to accept further appropriate treatment, and I have reasonable
basis to believe that you can be committed to a hospital, I must
seek said commitment and may contact members of your family or other
individuals if it would assist in protecting you.
-
Worker’s
Compensation: If you file a workers’ compensation claim,
your records relevant to that claim will not be confidential to
entities such as your employer, the insurer and the Division of
Worker’s Compensation.
IV. Patient’s
Rights and Mental Health Professional’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 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 circumstance, 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.
Mental Health
Professional’s Duties:
-
I am required
by law to maintain the privacy to 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 provide a written copy 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 Ethan Pollack,
Ph.D., or Sanford Portnoy, Ph.D., at 781-449-8161.
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 April 14, 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 mail or in person.
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