Privacy Policy

OHIO NOTICE FORM POSTED AS REQUIRED BY FEDERAL LAW

PSYCHOLOGISTS’ POLICIES & PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully and keep it for future reference. According to federal law I must provide you with this information which describes how psychological and medical information about you may be used and disclosed. Please read about these policies and practices and consider the impact they may have on your life.

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

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. Here are definitions of these terms:

PHI refers to information in your health record that could identify you. It includes information about your symptoms, test results, diagnosis, treatment, and related medical information.

Treatment, Payment, and Health Care Operations

Treatment is when I provide, coordinate or manage your health care and other services related to your care. An example would be when I consult with another health care provider, such as your family physician or specialist.

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 my services to you or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of my practice. Examples of this are quality assessment and improvement activities, business-related matters (such as audits and administrative services), case management, and care coordination.

Use applies only to activities within my practice, such as sharing 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.

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 specified disclosures. In these instances when I am asked for information, I will obtain a written authorization from you before releasing this information. I will also need to obtain an authorization before releasing psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during an individual, group, joint, or family counseling session, which I have kept separate from the rest of your record according to law. These notes are given more protection than PHI. You may revoke all such authorizations (for PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke and 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.I will also obtain an authorization from you before using or disclosing:

  • PHI in a way that is not described in this Notice.
  • Psychotherapy notes PHI for marketing purposes.
  • PHI in a way that is considered a sale of PHI.

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, in my professional capacity, I know or suspect that a child under age 18 or a mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has suffered or faces a threat off suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, I am required by law to immediately report that knowledge or suspicion to the Ohio Public Children Services Agency, or a municipal or county peace officer.
  • Adult and Domestic Abuse – If I have reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, I am required by law to immediately report such belief to the County Department of Job and Family Services.
  • Judicial or Administrative Proceeding – If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law and I will not release this information without written authorization from you or your persona or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. You would be informed in advance if this were the case.
  • Serious Threat to Health or Safety – If I believe that you pose a clear and substantial risk of imminent serious harm to yourself or another person, I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and /or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I am required by law to take one or more of the following actions in a timely manner:
    • Take steps to hospitalize you on an emergency basis
    • Establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional
    • Communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim’s parent or guardian if a minor, all of the following information – the nature of the threat, your identity, and the identity of the potential victim(s).
  • Worker’s Compensation – If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.
    When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy rule and the state’s confidentiality laws. This includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

IV. Patient Rights and Psychologist Duties

Patient 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 at your request.
  • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communication 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.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. On your request I will discuss with you the details of the amendment process. I may accept or deny your request.
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have not provided either consent or 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 Restrict Disclosures when you have paid for Your Care Out-Of-Pocket - You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.
  • Right to be notified if there is a Breach of Unsecured PHI - You have a right to be notified if :(a) there is a breach (a use or disclosure of your PHI in violation of the HIPPA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
  • 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.Psychologist Duties
      • I am required by law to maintain the privacy of 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, if these changes affect your PHI, send notice of these changes to you by regular mail at your last known address to me.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at Sheryl L. Cohen, Ph.D. 9200 Montgomery Road #10A Cincinnati, Ohio 45242 513-791-7022 Ext.11

If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to Sheryl L. Cohen, Ph.D. 9200 Montgomery Road #10A Cincinnati, Ohio 45242 513-791-7022 ext.11

You may also send a written complaint to the Secretary of the US Department of Health and Human Services.

The person listed above can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. I will not retaliate against your for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice went into effect on April 13, 2003

I will limit the uses or disclosures that I will make as follows: to comply with current laws.

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 regular mail at your last known address I have noted in my files.