NOTICE OF PRIVACY POLICIES AND PRACTICES AND COMPLIANCE WITH HIPAA REGARDING CONFIDENTIALITY OF CLIENT RECORDS AND DISSEMINATION OF INFORMATION
Given the nature of our work, it is imperative that we maintain the confidence of client information that we receive in the course of our work. Denver Family Therapy Center, Inc. (herein “DFTC”) is a private mental health counseling practice that provides mental health services to individuals, couples, and families. The practice works solely to provide the best counseling treatment options to its clients. DFTC prohibits the release of any client information to anyone outside immediate staff, employees, interns, or volunteers except in limited circumstances. Discussion or disclosure of protected health information (hereinafter “PHI”) within the organization is limited to the minimum necessary that is needed for the recipient of the information to perform their job. Please review this Notice of Privacy Policies and Practices and Compliance with HIPAA Regarding Confidentiality of Client Records and Dissemination of Information. It is the policy of DFTC to:
- Fully comply with the requirements of the HIPAA General Administrative Requirements, the Privacy and Security Rules;
- Provide every patient who receives services with a copy of this Notice of Privacy
Policies and Practices; - Ask the patient to acknowledge receipt when given a copy of this Notice of
Privacy Policies and Practices: - Ensure the confidentiality of all patient records transmitted by facsimile;
- Provide each client with the individual therapists’ informed Authorization for use
or disclosure of Protected Health Information form.
DFTC is required to follow all state statutes and regulations including Federal Regulation 42 C.F.R. Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142, 160, 162 and 164, governing testing for and reporting of TB, HIV AIDS, Hepatitis, and other infectious diseases, and maintaining the confidentiality of protected health information.
Protected health information (PHI) refers to any information that is created or received by DFTC, and relates to an individual’s past, present or future physical or mental health or conditions and related care services or the past, present, or future payment for the provision of health care to an individual; and That identified the individual; With respect to which there is a reasonable basis to believe the information can be used to identify the individual; or PHI includes any such information described above that DFTC transmits or maintains in any form, the includes Psychotherapy Notes. HIPAA and federal law regulates the use and disclosure of PHI when transmitted electronically.
YOUR RIGHTS AS A CLIENT
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your mental health record
- You can ask to see or get an electronic or paper copy of your mental health records and other health information we have about you. Ask us how to do this.
- We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your mental health record
- You can ask us to correct health information about you that you think is incorrect
- or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications
- You can ask us to contact you in a specific way (e.g. home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
- Please review the Consent for Communication of Protected Health Information by Non- Secure Transmissions
- You are required to “opt-in” to receive communications electronically as set-forth in the Consent for Communication of Protected Health Information by Non-Secure Transmissions. If you choose not to “opt-in” to receive electronic communications, we will not communicate with you via electronic means.
Ask us to limit what we use or share
- The phone numbers collected by DFTC and the consent received by DFTC is never shared with third party providers without consent. Additionally, DFTC NEVER sells personal contact information.
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for services or health care item out-of-pocket or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C., 20201; calling 1-877-696-6775; or visiting www.hhs.gov/ocr/privacy/hippa/complaints/. We will not retaliate against you for filing a complaint. You may also file a complaint with the Colorado Department of Regulatory Agencies, Division of Professions and Occupations, Mental Health Section; 1560 Broadway, Suite 1350, Denver, CO, 80202; 1-303-894-7800; DORA_Mentalhealthboard@state.co.us. Please note that the Department of Regulatory Agencies may direct you to file your complaint with the U.S. Department of Health and Human Services Office for Civil Rights listed above.
USES AND DISCOLSURES OF PROTECTED HEALTH INFORMATION
Use of PHI occurs within a covered entity (i.e. discussions among staff regarding treatment). A disclosure of PHI occurs when a DFTC reveals PHI to an outside party (i.e. DFTC provides another treatment provider with PHI or shares PHI with a third party pursuant to a client’s valid written authorization). HIPPA and federal law regulate the disclosure of PHI by electronic transmissions. DFTC may use and disclose PHI, without an individual’s written authorization, for the following purposes:
- Treatment (including the provision and coordination of care with other professionals, etc.)
- Payment (to bill and get payment from health plans or other entities, claims management, etc.)
- Health care operations (general administrative activities and operation of DFTC, resolution of internal grievances, customer service, etc.)
Uses and disclosures for payment and health care operations purposes are subject to the minimum necessary requirement. This means that DFTC may only use or disclose the minimum amount of PHI necessary for the purpose of the use of disclosure (i.e. for billing purposes, a therapist would not need to disclose a patient’s entire medical record in order to receive reimbursement, rather a therapist would likely only need to include a service code, etc.).
DFTC’s confidentiality of client records and substance abuse client records maintained is protected by federal law and regulations. It is DFTC policy that a patient must complete an Authorization for Use or Disclosure of Protected Health Information (Attachment 1), provided by DFTC, prior to disclosing health information for any purpose, except for treatment, payment or health care operations.
Absent the above referenced form, other than for treatment, payment, or health care operations purposes, the DFTC staff is prohibited from disclosing or using any PHI outside of or within the organization, including disclosing that the client is in treatment, unless one of the following exceptions arises:
DFTC is permitted and/or required to report or disclose PHI if and when any of thefollowing occur with any DFTC client:
- Responding to lawsuit and legal actions (Disclosure by a court order, in response to a complaint filed against a counselor of DFTC, etc.)
- Disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.
- Help with public health and safety issues (Client commits or threatens to commit a crime either at the program or against any person who works for the program; A minor or elderly client reports having been abused; Client is planning to harm another person, including but not limited to the harm of a child; Client reports suicidal ideations or self-harm).
- Address workers’ compensation, law enforcement, and other government requests.
- Respond to organ and tissue donation requests.
- In compliance with other state and/or federal laws and regulations.
The above exceptions are subject to several requirements under the Privacy Rule, including the minimum necessary requirement (you may only use and disclose the minimum amount of PHI necessary for the intended purpose of the use and/or disclosure) and applicable federal and state laws and regulations. See 45 C.F.R. § 164.512. Before using or disclosing PHI for one of the above exceptions, consult DFTC Privacy Officer to ensure compliance with Privacy Rule. Violation of theses federal and state guidelines is a crime carrying both criminal and monetary penalties. Suspected violations may be reported to appropriate authorities in accordance with federal and state regulations. Know that DFTC will never market or sell your personal information.
SPECIAL AUTHORIZATIONS
Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.
Psychotherapy Notes: I will obtain a special authorization before releasing your Psychotherapy Notes and test results. “Psychotherapy Notes” are notes I have made about our conversations during private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.
HIV Information: Special legal protections apply to HIV/AIDS related information. I will obtain a special written authorization from you before releasing information related to HIV/AIDS.
Alcohol and Drug Use Information: Special legal protections apply to information related to alcohol and drug use and treatment. I will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV Information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. 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, law provides the insurer the right to contest the claim under the policy.
As a covered entity under the Privacy and Security Rules, DFTC is required to reasonably safeguard PHI from impermissible uses and disclosures. Safeguards may include, but are not limited to the following:
- Not leaving lab results unattended where third parties without a need to know can view them.
- Any PHI received as a DFTC employee, intern or volunteer about a client or potential DFTC client, may not be used or disclosed for non-work purposes or with unauthorized individuals. DFTC may only use and disclose such PHI as described above.
- When speaking with a client about their PHI where third parties could possibly overhear, move the conversation to a private area.
- Seek legal counsel in uncertain situations and/or incidences.
YOUR CHOICES
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. We may request you sign a separate document if you authorize us to share certain PHI. You may revoke that authorization at any time for further disclosure.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care.
- Share information in a disaster relief situation.
- Include your information in a hospital directory.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Changes to Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
This notice is effective April 4, 2018.