Notice of Policies and Practices to Protect the Privacy of Your Health Information

The privacy of your health information is important to IPG. We will maintain the privacy of your health information and will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

A new federal law commonly known as HIPAA requires that we take additional steps to keep you informed about how we might use information that is gathered in order to provide health care services to you. As part of this process, IPG is required to provide you with the following Notice of Privacy Practices and to request that you sign a written acknowledgement that you received a copy of the Notice. The Notice describes how we may use and disclose your “Protected Health Information” (or “PHI”) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information IPG maintains about you and a brief description of how you may exercise these rights.

I.    Uses and Disclosures for Treatment, Payment, and Health Care Operations

We 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 we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when your therapist consults 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 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 our offices such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our offices such as releasing, transferring, or providing access to information about you to other parties.

II.  Uses and Disclosures Requiring Authorization

IPG 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 IPG is asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. IPG will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your therapist has made about your conversation during a private, group, joint, or family counseling session, which he or she has 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) IPG has 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

IPG may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If your therapist has reasonable cause to believe that a child has been subject to abuse or neglect, he or she must report this immediately to the New Jersey Division of Youth and Family Services.
• Adult and Domestic Abuse: If your therapist reasonably believes that a vulnerable adult is the subject of abuse, neglect, or exploitation, he or she may report the information to the county adult protective services provider.
• Health Oversight: If the New Jersey State Board of Psychological Examiners issues a subpoena, your therapist may be compelled to testify before the Board and produce your relevant records and papers.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that have been provided to you and/or the records thereof, such information is privileged under state law, and we must not release this information without written authorization from you or your legally appointed representative, 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. IPG must inform you in advance if this is the case.
• Serious Threat to Health or Safety: If you communicate to your therapist a threat of imminent serious physical violence against a readily identifiable victim or yourself or the public and he or she believes you intend to carry out that threat, your therapist must take steps to warn and protect. He or she must take such steps if it is believed you intend to carry out such violence, even if you have not made a specific verbal threat. The steps taken to warn and protect may include arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, and warning your parents if you are under 18.
• Worker’s Compensation: If you file a worker’s compensation claim, IPG may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

IV.  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, IPG is 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 a therapist. Upon your request, IPG can 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 the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. IPG may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we 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. IPG may deny your request. On your request, IPG 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, we 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 IPG upon request, even if you have agreed to receive the notice electronically.

V.  Questions and Complaints

If you have questions about this notice, disagree with a decision IPG makes about access to your records, or have other concerns about your privacy rights, you should inform us of your concerns.

If you believe that your privacy rights have been violated and wish to file a complaint with IPG, you may send your written complaint to IPG at the address on the reverse. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. IPG 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 February 1, 2015.

IPG reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that IPG maintains. If IPG changes this Notice, we will post the revised Notice in the waiting area of our offices.

This form is educational only, does not constitute legal advice, and covers only federal, not state, law.