HIPAA Privacy Authorization Information

Authorization for Use or Disclosure of Protected Health Information

The Health Insurance Portability and Accountability Act (HIPAA) establishes patient rights and protections associated with the use of protected health information. HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care providers. Providers and health care agencies are required to provide patients a notification of their privacy rights as it relates to their health care records.

This Patient Notification of Privacy Rights informs you of your rights. Please carefully read this Patient Notification. It is important that you know and understand the patient protections HIPAA affords you as a patient.

In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship; therefore, I will do all we can do to protect the privacy of your mental health records. If you have questions regarding matters discussed in this Patient Notification, please do not hesitate to ask.

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

Records are kept documenting your care as required by law, professional standards, and other review procedures. HIPAA clearly defines what kind of information is to be included in your “designated medical record” or “case record” as well as some material, known as “Psychotherapy Notes”. HIPAA provides privacy protections about your personal health information, which is called “protected health information (PHI)” which could personally identify you. PHI consists of three (3) components: treatment, payment, and health care operations.

Treatment refers to activities/sessions I provide, coordinate or manage your mental health care service or other services related to your health care. Examples include a counseling session or communication with your primary care physician about your medication or overall condition.

Payment is when Impressions Therapy, LLC obtains reimbursement for your mental health care or other services related to your health care.

Health care operations are activities related to my performance such as quality assurance. The use of your protected health information refers to activities my agency conducts for scheduling appointments, keeping records, and other tasks related to your care. Disclosures refer to activities you authorize such as the sending of your protected health information to other parties.

II. Uses and Disclosures of Protected Health Information Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or 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 I am asked for information for purposes outside of treatment, payment or health care operations, I 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 I have relied on that authorization.

III. Uses and Disclosures Not Requiring Consent or Authorization

By law, protected health information may be released without your consent or authorization under the following conditions:

• Suspected or known child abuse or neglect

• Suspected or known sexual abuse of a child

• Adult and Domestic abuse

• Judicial or administrative proceedings

o If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without the written authorization from you or your personal or 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. I will inform you in advance if this is the case.

• Serious threat to health or safety (i.e., “Duty to Warn” and Threat to National Security)

o If you communicate to me a serious threat of physical violence against a reasonably identifiable victim or victims, I must communicate such threat to the victim or victims and to a law enforcement agency.

IV. Patient’s Rights and My Duties

You have a right to the following:

• The right to request restrictions on certain uses and disclosures of your protected health information which I may or may not agree to but if I do, such restrictions shall apply unless our agreement is changed in writing

• The right to receive confidential communications by alternative means and at alternative locations.

• The right to a copy of your protected health information in the designated record and any billing records for as long as protected health information is maintained in the record.

• The right to amend an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

• The right to an accounting of non-authorized disclosures of your protected health information.

• The right to a paper copy of notices/information from Impressions Therapy, LLC.

• The right to revoke your authorization of your protected health information except to the extent that action has already been taken.

Impressions Therapy, LLC is required by law to maintain the privacy of your protected health information and to provide you with a notice of your Privacy Rights and our duties regarding your PHI. Impressions Therapy, LLC reserves the right to change its privacy policies and practices as needed with these current designated practices being applicable unless you receive a revision of these policies when you come for future appointment(s). Our duties in these matters include maintaining the privacy of your protected health information, to provide you with a notice of your rights and our privacy practices with respect to your PHI, and to abide by the terms of the notice unless it is changed and you are so notified.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may file a grievance. You have the right to receive oral or written instructions for filing a grievance. The right to file a grievance is not time limited. If you need assistance in filing a grievance or want further information, please contact me or the office and we can provide you with that information.