Washington Notice Form

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

 THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 I.  Examples of Uses and Disclosures of Protected Health Information for Treatment, Payment, and Health Care Operations 

Melissa McCreery, Ph.D.  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 a provider provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when a provider consults with another health care provider, such as your family physician or another mental health provider. 

• Payment is when provider obtains reimbursement for your healthcare.  Examples of payment are when provider discloses 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 provider’s 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 a provider’s office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of provider’s office, such as releasing, transferring, or providing access to information about you to other parties.

 II.  Uses and Disclosures Requiring Authorization

Provider 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 a provider is asked for information for purposes outside of treatment, payment and health care operations, provider will obtain an authorization from you before releasing this information. 

You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) the provider 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

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

 §     Child Abuse: If provider has reasonable cause to believe that a child has suffered abuse or neglect, provider is required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services. 

§     Adult and Domestic Abuse: If provider has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, provider must immediately report the abuse to the Washington Department of Social and Health Services. If provider has reason to suspect that sexual or physical assault has occurred, provider must immediately report to the appropriate law enforcement agency and to the Department of Social and Health Services.    

§     Health Oversight: If the Washington Licensing Board subpoenas provider as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed providers, provider must comply with its orders.  This could include disclosing your relevant mental health information. 

§    Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that provider has provided to you and the records thereof, such information is privileged under state law, and provider will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform provider that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

§    Serious Threat to Health or Safety: Provider may disclose your confidential mental health information to any person without authorization if provider reasonably believes that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual.  

§      Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, provider must make available, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury in the opinion of the Washington Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.

IV.  Other Uses and Disclosures of Protected Health Information

Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

V.  Patient's Rights and Provider’s Duties

Patient’s Rights: 

• Receive, read, and ask questions about this Notice – You have the right to request and receive a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Washington Notice Form”) from your provider.

• Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you.  You must deliver this request in writing to your provider.  However, your provider is not required to agree to a restriction you request but will comply with any request granted.

• Cancel prior authorizations – You have the right to cancel prior authorizations to use or disclose health information by giving written revocation to your provider.  Your revocation does not affect information that has already been released.  It also does not affect any action taken before your provider has your revocation.  Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

• 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 receiving treatment.  Upon your written request, your provider will send your PHI to another address.) 

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your provider’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  Upon your request, your provider 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. Your provider may deny your request.  On your request, your provider will discuss with you the details of the amendment process.  You may write a statement of disagreement if your request is denied.  It will be stored in your medical record and included with any release of your records.

• 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).  This will not include disclosures to third-party payors.  You may obtain this information without charge once every 12 months.  Your provider will notify you of the cost involved if you request this information more than once in 12 months. 

Provider’s Duties:

• Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
• Your provider reserves the right to change the privacy policies and practices described in this Notice. Unless your provider notifies you of such changes, however, your provider is required to abide by the terms currently in effect.
• Your provider has the right to change his/her practices regarding the protected health information he/she maintains.  If your provider make changes and you are an active patient in his/her practice, he/she will provide you with a copy of the updated Notice at your first visit after the change.  You may always receive the most recent copy of this Notice by calling your provider and asking for it or by visiting your provider’s office to pick one up.

VI.  To Ask for Help or Complain

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Melissa McCreery, Ph.D.

1201 11th Street, Suite 200B

Bellingham, WA 98225

(360) 671-8520

If you believe your privacy rights have been violated, you may discuss your concerns with your provider or the above noted person.  You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  The person listed above can provide you with the appropriate address upon request. 

VII.  Web Site

• Melissa McCreery, Ph.D. has a Web Site that provides information about her background and practice.  For your benefit, this Notice is on the Web Site at this address:  www.drmccreery.com

 VIII. Effective Date 

This notice will go into effect on April 14, 2003.