Notice of Policies and Practices to Protect the Privacy of Your Health Information: Health Insurance Portability Accountability Act (HIPAA)

Birkley Consulting, LLC

513-447-3223

erica@birkleyconsulting.com

PO Box 30435, Cincinnati, OH 45230

FOR PERSONS PARTICIPATING IN A WELL VISIT, THIS NOTICE DESCRIBES HOW MENTAL HEALTH 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 Well Visit, Attendance, and Health Care Operations

I may use or disclose your protected health information (PHI) for well visit, attendance, and health care operations purposes in most instances without your consent under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), but I will obtain consent in another form for disclosing PHI for other reasons, including disclosing PHI outside of my practice, except as otherwise outlined in this Policy. In all instances I will only disclose the minimum necessary information in order to accomplish the intended purpose.

To help clarify these terms, here are some definitions:

·      “PHI” refers to information in your health record that could identify you and stands for protected health information.

·      “Well Visit” is when I provide a consultation appointment. You specifically understand and agree that you are not receiving treatment or health care from me and that I do not consider myself to be treating you.

·      “Attendance” is when I provide your agency with a signed attendance report for the scheduled time of your well visit that will include your full name and date of the visit.

·      “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 mandated documentation and reporting.

·      “Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

·      “Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.

Following your assigned well visit, I will give your agency a signed attendance report that will include your full name and date of the well visit. There will be no PHI on billing invoices from me to the city or municipality representative(s) of your agency.

In general, I will not be taking notes or professional documentation of contents the well visit, with a few exceptions further described in sections below.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, attendance, 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, attendance, and health care operations, I will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your agency, or other third party, except in some limited instances where they are involved in your health care (for example, transportation to a hospital facility), in which case I will obtain your consent first. Any disclosure involving well visit documentation, if I am required to maintain them, will require your signed authorization, unless I am otherwise allowed or required by law to release them. You may revoke an authorization for future disclosures, but this will not be effective for past disclosures which you have authorized. In most legal proceedings, you have the right to prevent me from providing any information about your well visit. In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order. 

III. Uses and Disclosures Requiring Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization as allowed by state or federal statutory, regulatory or common law, including but not limited to, the Health Insurance Portability and Accountability Act of 1996, and Chapter 3798 of the Ohio Revised Code (ORC) on Protected Health Information, including under the following circumstances:

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to disclose otherwise confidential information.  For example, if I believe that a child, elderly person, or disabled person is being abused or has been abused, I am required to make a report to the appropriate state agency.

If I believe that you are threatening serious bodily harm to another, with the imminent intention and means to deliver harm, I am required to take protective actions.  These actions will include notifying the potential victim(s), contacting the police, and seeking emergency hospitalization for you, which includes transportation by public safety professionals. If you threaten to harm yourself, or at imminent risk of harming yourself, I may be obligated to seek hospitalization for you and/or to contact family members or others who can help provide protection. If a similar situation to the ones described above occurs in the course of the well visit, I will attempt to fully discuss it with you and obtain your written consent if possible and appropriate, before taking any action.

In the event de-identified information from your well visit is used for research purposes, procedures will be put in place to ensure that your identity is not revealed, for example, by sharing data aggregated across agencies to protect privacy and confidentiality. If I know or have reasonable cause to believe that you have been the victim of domestic violence, I must note that knowledge or belief and the basis for it in a professional written record.

IV. Patient’s Rights

Right to Request Restrictions and Disclosures: You have the right to request restrictions on certain uses and disclosures of protected health information about you for well visit, attendance, or health care operations. However, I am not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case.

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the attendance report given to your agency and if applicable, my records used to make decisions about you, for example in the case of mandatory reporting, for as long as the PHI is maintained in the record, except under some limited circumstances. If I maintain the information in an electronic format you may obtain it in that format. This does not apply to information created for use in a civil, criminal or administrative action or proceeding. I may charge you reasonable amounts for copies, mailing, or associated supplies under most circumstances. I may deny your request to inspect and/or copy your record or parts of your record in certain limited circumstances. If you are denied copies of or access to your PHI, you may ask that my denial be reviewed.

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, but will note that you made the request. Upon your request, I will discuss with you the details of the amendment process.

Right to an Accounting: With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, attendance, or health care operations for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for well visit, attendance, or health care operations, for a period of six years. At 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.

V. My Duties

I am required by law to maintain the privacy of PHI, to provide you with this notice of my legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.

I reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI I maintain.

If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the revised notice to you on my website. You can always request that a paper copy be sent to you by mail.

In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI, unless there is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.

VI. Complaints

If you are concerned that I have violated your privacy rights or you disagree with a decision I make about access to your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me, the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 200 Independence Avenue S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/compliants/. There will be no retaliation against you for filing a complaint.

VII. Effective Date

This notice is effective as of March 12, 2023.

VIII. Privacy and Security Officer

Erica Birkley, PhD acts as Privacy and Security Officer. Her contact information is listed at the beginning of this form. You can find her listed with the Ohio Board of Psychology and the Kentucky Board of Examiners of Psychology.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By providing your dated and witnessed signature below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY PROVIDING MY DATED AND WITNESSED SIGNATURE BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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Your Name                                                          Date

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Witnessed By                                                     Date