Your privacy is protected by the Health Insurance Portability and Accountability Act
NOTICE OF PRIVACY PRACTICES FOR
PERSONAL HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Summary
This Notice describes how yours or your child's personal health information (PHI) is protected, and how the ACTA clinical staff may use and disclose this information. PHI includes personally identifiable information that relates to yours or your child's past, present, or future health, treatment, or payment for health care services. ACTA's employees and professional staff are required to comply with this privacy policy, and have access to this information only when there is an appropriate reason to do so, such as to confer with other health care providers or to submit claims for these services.
Under the Health Insurance Portability and Accountability Act (HIPAA), you are afforded privacy rights regarding the use and disclosure of your health information. These include:
• a right to be informed of the potential uses and disclosures of yours or your child's protected health information, and to limit those uses and disclosures of this protected health information;
• a right to receive this written notice that explains how we may use and disclose yours or your child's protected health information, your rights under HIPAA's privacy rule, and the ACTA clinical staff's responsibilities as a covered entity under HIPAA;
• a right to a paper copy of this notice, or to have your legally designated representative receive a copy of this notice; you are asked to acknowledge receipt of this notice;
• a right to amend yours or your child's record, to restrict what information from yours or your child's record is disclosed to others, and to receive an accounting of disclosures of this information that were made without your authorization, other than for treatment, payment or health care operations;
• a right to have your complaints about my policies and procedures recorded in these records.
As a health care provider, the ACTA clinical staff is making a good faith effort to see that you or your representative have received and acknowledged this notice of privacy practices. If you or your child is seen for emergency treatment, you will receive this notice as soon as practically possible afterward.
I. Disclosures for Treatment, Payment,
and Health Care Operations
The ACTA clinical staff may use or disclose yours or your child's protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. To help clarify these terms, here are some definitions:
• PHI refers to information in yours or your child's health record that could identify you or your child.
• Treatment is when the ACTA clinical staff or another healthcare provider diagnoses or treats you or your child. An example of treatment would be when the ACTA staff consults with another health care provider, such as your family physician or another psychologist, regarding yours or your child's treatment.
• Payment is when the ACTA staff obtains reimbursement for yours or your child's healthcare. Examples of payment are when ACA staff discloses yours or your child's PHI to your health insurer to obtain reimbursement for yours or your child's health care or to determine eligibility or coverage.
• Health Care Operations is when ACTA staff discloses yours or your child's PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
• Use applies only to activities within the ACTA office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you or your child.
• Disclosure applies to activities outside of the ACTA office, such as releasing, transferring, or providing access to information about you or your child to other parties.
• Authorization means written permission for specific uses or disclosures. All authorizations to disclose must be on a specific, legally required form.
II. Uses and Disclosures Requiring Authorization
The ACTA staff may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when the ACTA clinical staff is asked for information for purposes outside of treatment and payment operations, the ACTA clinical staff will obtain an authorization from you before releasing this information.
You may revoke or modify all such authorizations of PHI at any time, provided each revocation is in writing; however, the revocation or modification is not effective until the ACTA clinical staff receives it. You may not revoke an authorization to the extent that (1) the ACTA staff has relied on that information; 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
The ACTA clinical staff may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: Whenever the ACTA clinical staff, in their professional capacity, has knowledge of or observes a child the clinical staff member knows or reasonably suspects, has been the victim of child abuse or neglect, the ACTA staff member must immediately report such to a police department or sheriff's department, county probation department, or county or state welfare department.
Adult and Domestic Abuse: If the ACTA clinical staff members, in their professional capacity, have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if the ACTA clinical staff members are told by an elder or dependent adult that he or she has experienced these, or if the ACTA staff members reasonably suspect such, they must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency.
Health Oversight: If a complaint is filed against an ACTA clinical staff member with the State Board that licenses their profession, the Board has the authority to subpoena confidential mental health information from the ACTA staff member relevant to that complaint.
Serious Threat to Health or Safety: If you or your child communicates to an ACTA clinical staff member a serious threat of physical violence against an identifiable victim, the ACTA clinical staff member must make reasonable efforts to prevent harm, which may include communicating that information to the potential victim, and the police. If an ACTA clinical staff member has reasonable cause to believe that you or your child are in such a condition, as to be dangerous to yourself or others, the ACTA clinical staff member may release relevant information as necessary to prevent the threatened danger.
Judicial or Administrative Proceedings: If you or your child are involved in a court proceeding and a request is made about the professional services that an ACTA clinical staff member has provided you or your child, the ACTA clinical staff member must not release your information without your written authorization or the authorization of your attorney or personal representative; or a court order.
The privilege does not apply when you or your child is being evaluated for a third party or where the evaluation is court-ordered. ACTA clinical staff members will inform you in advance if this is the case.
IV. Patient's Rights and Provider's Duties
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 or your child. However, ACTA clinical staff 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 ACTA clinical staff members and may request that they not telephone your residence).
Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in ACTA's mental health and billing records used to make decisions about you or your child for as long as the PHI is maintained in the record. ACTA staff members may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, ACTA clinical staff members 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. ACTA clinical staff may deny your request. On your request, ACTA staff members 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, ACTA clinical staff members 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 the ACTA clinical staff upon request, even if you have agreed to receive the notice electronically.
Duties of Provider:
The ACTA clinical staff is required by law to maintain the privacy of PHI and to provide you with a notice of their legal duties and privacy practices with respect to PHI.
The ACTA clinical staff reserves the right to change the privacy policies and practices described in this notice. Unless the ACTA clinical staff member notifies you of such changes, however, they are required to abide by the terms currently in effect.
If the ACTA clinical staff revises their policies and procedures, the ACTA clinical staff will provide you with a written copy of the revised policies and procedures at the earliest possible opportunity following this revision, in person or by mail.
V. Complaints
If you are concerned that the ACTA clinical staff has violated yours or your child's privacy rights, or you disagree with a decision the ACTA clinical staff has made about access to yours or your child's records, you may contact the Compliance Officer for further information.
For complaints, contact Aron Bautista, MS or Dr. Byrne at (512) 282-2282, or:
Aron Bautista, MS and/or Claudia Byrne, Ph.D.
8103 Brodie Lane, Suite 1, Austin, TX 78745
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Dr. Byrne and/or Aron Bautista, MS will provide the appropriate address upon request.
VI. Effective Date, Restrictions, and
Changes to Privacy Policy
This notice went into effect June 1, 2007. The ACTA clinical staff reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that the ACTA clinical staff maintains. The ACTA clinical staff will provide you with a revised notice by mail, at the earliest opportunity following the revision.