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
-
“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.
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
VIII.
Effective Date
This notice
will go into effect on April 14, 2003.
