Your Rights to Privacy

• You have the right to request restrictions on certain uses and disclosures of protected health information about you. We will consider, but are not required to agree to, all restrictions you request.
  
• You have the right to request and receive confidential communications by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a psychologist. Upon your request, we will send your bills to another address.
  
• You have the right to inspect or obtain a copy of your information and psychotherapy notes in the mental health and billing records for as long as the information is maintained in the record, except under special circumstances.
  
• You have the right to request an amendment of your protected health information for as long as the information is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
  
• You generally have the right to receive an accounting of disclosures of protected health information for which you have neither provided consent nor authorization (as described in Section C of this Notice). On your request, I will discuss with you the details of the accounting process.
  
• 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.
  
• You have the right to revoke any authorizations to release information. This will prevent future release of information to that party.
  

Our Duties

• We are required by law to maintain the privacy of your protected health information and to notify you of our obligations and duties
  
• Except for treatment and under specified circumstances, we must use and disclose only the minimum necessary information to accomplish the purpose of the use or disclosure.
• We are required to follow the terms of this notice

Notice of Privacy Practices

This notice describes how medical and psychological information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Protected health information. Information about your health, treatment, or payment for your treatment is called "ProtectedHealth Information" when it is linked with your name or other information that can identify you.

This brochure describes how your protected health information is used and/or disclosed, including:

• The use and disclosure of your protected health information for treatment, payment, and health care operations.
  
• The disclosure of protected health information with the Ohio State University.
  
• When we will need to obtain your specific permission for disclosures for any purposes beyond treatment, payment, and health care operations.
  
• Your privacy rights and our duties to maintain your privacy
  

We reserve the right to change the terms of this notice, and make the new terms effective for all of our files. If the terms change, we will post the changes on our website <www.rehabpsych.org>. For more information about our privacy practices, or to file a complaint, contact your psychologist or John D. Corrigan, PhD (Privacy Officer) at 614/293-3830. Complaints can also be made to the Secretary of Health and Human Services. Retaliatory action will not be taken against a patient for exercising his or her rights or for bringing a complaint "in good faith".

Effective Date: April 14, 2003

A. When you receive services from use, we need to inform you that your protected health information will be used and disclosed for these purposes:

Use and disclosure of protected health information for treatment and payment. We use and disclose your protected health information for providing services to you and for obtaining payment for those services. For example,

• If a psychologist sees you for counseling, she or he will read your file to obtain background information about you.
  
• To obtain payment for our services, the psychologist or the division secretary will need to give your insurance company your diagnosis or other information.
  
• If you are working with a psychology trainee, both the trainee and the supervisor will review your records
  
• If you are working with a treatment team, information about you and your treatment may be shared with other treatment team members
  

Use and disclosure of protected health information for health care operations. We also use and disclose your protected health information for "health care operations". Examples include:

• Your information may be used to look for ways of improving our treatment and practice.
  
• Your contact information may be used to schedule an appointment, or let you know about services or information that may be of interest.
  
• Your file may be accessed by our staff for the purposes of obtaining contact information, copying records in preparation for disclosure, or other administrative purposes.
  
• Your information may be accessed for audits or reimbursement.
  

Use and disclosure for research and training purposes. Staff within our practice conduct research and train new psychologists. At times, your information may be reviewed in preparation for research, however if we decide to conduct the research and it involves information that could identify you, we will seek your consent to participate in the research. We may also use your information for training purposes, however it will be disguised so that you will not be identified.

Use and disclosure of information with Ohio State University. Because we are associated with the Ohio State University and its Medical Center, we have access to information in your medical records and we share protected health information with the Ohio State University for purposes of treatment, payment, and health care operations.

B. In some circumstances, we need you to give us written authorization for disclosing your protected health information.

• Disclosure to parties outside of Rehabilitation Psychology, Inc. or the Ohio State University, will need written authorization from you, with the exception of circumstances noted under section A. For example, your authorization is needed to send information to your attorney.
  
• Some of the contents of your therapy sessions may be separated from your file and only released to an outside party with your specific authorization (see exceptions in section C); these notes are called psychotherapy notes. Talk to your psychologist if you want psychotherapy notes to be treated differently than other records.
  

C. There are some circumstances for which we do not need your permission to release your information. These include:

• If child or elder abuse/neglect is suspected, the psychologist is required by law to report the abuse to the proper public authorities.
  
• If domestic violence is suspected, the psychologist is required to document that knowledge.
  
• If it is believed that you pose a serious, imminent threat of harm to yourself or others, the psychologist is required by law to take action, which may involve disclosure of information about you to another provider, law enforcement, your family, or the potential victim.
  
• If services are being provided at the request of a third party, then the psychologist will be required to release those records to them. This includes the Bureau of Workers Compensation, the Ohio Rehabilitation Services Commission, the State Teachers Retirement System, the Social Security Administration, and the courts. The third-party does not allow you to access these records, you will be informed at the start of the services.
  
• For government or health care oversight activities

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