[vc_row][vc_column width=”1/1″][heading level=”2″ include_line=”0″ alignment=”center” heading=”Privacy Policy”][/vc_column][/vc_row][vc_row][vc_column width=”1/1″][text]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.

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

Still Waters may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. 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 we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
– Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose 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 our 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 our office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.
· “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained, such as to a member of your family, a relative, a close friend or any other person that you identify as involved in your healthcare. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage. The law provides the insurer the right to contest the claim under the policy. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

III. Uses and Disclosures with Neither Consent nor Authorization

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

· As Required By Law – We may use or disclose your PHI to the extent that is required
by law.

· Child Abuse – If we believe that a child is a victim of child abuse or neglect, we must report this belief to the appropriate authorities.

· Adult and Domestic Abuse – If we believe or have reason to believe that an individual is an endangered adult, we must report this belief to the appropriate authorities.

· Health Oversight Activities – If the Indiana Attorney General’s Office (who oversees complaints brought against psychologists instead of the Indiana Sate Psychology Board) is conducting an investigation into our practice, then we are required to disclose PHI upon receipt of a subpoena.

· Judicial and Administrative Proceedings – If the patient is involved in a court proceeding and a request is made for information about the professional services we provided you and/or the records thereof, such information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative 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 – If you communicate to us an actual threat of violence to cause serious injury or death against a reasonably identifiable victim or victims or if you evidence conduct or make statements indicating an imminent danger that you will use physical violence or use other means to cause serious personal injury or death to others, we may take the appropriate steps to prevent that harm from occurring. If we have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, we may need to disclose information in order to protect you. In both cases, we will only disclose what we feel is the minimum amount of information necessary.

· Worker’s Compensation – We may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Psychologist’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. You must put this request in writing. However, we are not required to agree with your 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 a therapist. On your request, Still Waters 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 your mental health record except in limited circumstances. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

· Right to Amend – You have the right to request an amendment and/or addendum to your mental health record. Your request must be in writing and give a reason for the request. We may deny your request. If we accept your request, we do not delete any information already in your records. If necessary, we will discuss with you the details of the amendment process further.

· Right to an Accounting – You have the right to receive an accounting of certain disclosures of PHI. You must put your accounting request in writing. If necessary, we will discuss with you the details of the accounting process further.

· Right to a Paper Copy – You have the right to obtain a paper copy of this notice from us when you receive care at Still Waters.

Psychologist’s Duties:

· We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

· We will let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI. We will notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered.

· We will follow the duties and privacy practices described in this notice and give you a copy of it.

· We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

· We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes; however, we are required to abide by the terms currently in effect.

· If we revise our policies and procedures, the new notice will be available upon request, in our office, and on our website.

V. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the HIPAA Privacy Officer, Robyn Palsrok, at Still Waters Professional Counseling at (765) 281-2952.

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.

This notice was originally effective on April 14, 2003, and was revised on September 23, 2013.[/text][/vc_column][/vc_row]