Christina M. Strain, LICSW 18 Vining Hill Road Southwick, MA 01077 (860) 539-5369 ______________________________________________________________________
Notice of Privacy Practices
Effective: January 2, 2008
Policy A Notice of Privacy Practices will be given to every client. Copies of each version of the Notice will be retained for six (6) years. Procedure 1. The Notice of Privacy Practices is the official description of: 1.1 How Christina M. Strain uses Protected Health Information (PHI); 1.2 When Christina M. Strain may disclose PHI; 1.3 The rights of the client with respect to PHI; and 1.4 Christina M. Strain’s legal duties with regard to PHI. The Notice of Privacy Practices will reflect other state and federal laws that impact Christina M. Strain’s privacy practices. 2. The Notice of Privacy Practices is approved by the Privacy Officer (Christina M. Strain). She is responsible for revising the Notice of Privacy Practices to reflect any changes in practices regarding PHI. The Notice is written in plain language. 3. The Notice of Privacy Practices is posted in a prominent location accessible to clients. The Notice is also available electronically through Christina M. Strain’s website, www.healthhealhope.com. 4. A copy of the Notice of Privacy Practices will be given to the client at the time of the first service delivery. EXCEPTION: If treatment is first rendered in an emergency, the Notice is given as soon as reasonably practicable after resolution of the emergency. 5. Christina M. Strain will ask the client to sign a written acknowledgement of receipt. If the client refuses or is unable to sign, the circumstances will be documented on the acknowledgement form. The acknowledgement form will be retained in the client’s record for six (6) years. 6. The Notice will be promptly revised whenever there is a material change to uses or disclosures of information, the individual’s rights, Christina M. Strain’s legal duties or other privacy practices stated in the Notice. The revised Notice will be made available at each service delivery site for continuing clients to take with them upon request and will be posted on www.healthhealhope.com, if applicable. Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â References 45 C.F.R. 164.520(a) Christina M. Strain, LICSW 18 Vining Hill Road Southwick, MA 01077
Notice of Privacy Practices This notice describes how medical and mental health information about you/your child may be used and disclosed and how you can get access to this information. Please review this notice carefully. Your/your child’s health record contains personal information about you/him/her and your/his/her health. Personal Health Information (PHI) is information about you/your child that may identify you/him/her and that relates to your/his/her past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes how I, Christina M. Strain, may use and disclose your/your child’s PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your/your child’s rights regarding how you may gain access to and control your/his/her PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, www.healthhealhope.com, and providing one to you at your next appointment. How I May Use and Disclose Health Information About You/Your Child For Treatment. Your/your child’s PHI may be used and disclosed by those who are involved in your/your child’s care for the purpose of providing, coordinating or managing your/your child’s health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization. For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you/your child. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your/your child’s insurance company, reviewing services provided to you/your child to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection. For Health Care Operations. I may use or disclose, as needed, your/your child’s PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing and conducting or arranging for other business activities. For example, I may share your/your child’s PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your/your child’s PHI. For training or teaching purposes PHI will be disclosed only with your authorization. Judicial and Administrative Proceedings. In any judicial or administrative proceeding, you have the right to refuse to authorize the disclosure of any communication between you, your child and me relating to your child’s care and treatment. There are a few instances in which this privilege would not apply, and therefore, in which I could testify in the judicial or administrative proceeding. Specifically, I may disclose such communications during judicial or administrative proceedings, if: (i) I determine that you/your child needs hospitalization or is a threat to your/him/herself or to others; (ii) The communications were made in the course of a court-ordered psychiatric examination; (iii) You/your child is a party to a case and has introduced your/his/her mental or emotional state as an element of a claim or defense; (iv) The testimony is given in connection with a care and protection proceeding, or a petition to dispense with parental consent to adoption; (v) It is in connection with any malpractice action brought by you against me, where the disclosure is necessary for my defense; (vi) The communications relate to your ability to provide care or custody in a child custody or adoption case; (vii) The communications were made in connection with and during an investigation of allegations of child abuse, when I have made a report that I have reasonable cause to believe that child abuse is occurring; or (viii) I believe a child, a disabled person, or an elderly person in your care is suffering abuse or neglect. In an Emergency. I may disclose your/your child’s PHI to a physician who requests such records in the treatment of a medical or psychiatric emergency. For example, if you/your child is unconscious and the doctor treating you/him/her needs to know details regarding your/his/her medical history in order to decide on a course of treatment for you/your child, I would disclose the PHI necessary for the doctor to treat you/your child during the emergency. If it is not possible to obtain your consent to this disclosure, then notice of the disclosure will be provided to you as soon as possible. Business Associates. Some services in my business I may obtain through contracts with business associates. For example, I may contract with outside companies to provide legal services, accounting services, or billing services. When I contract with a business associate, I may disclose health information to the business associate so it can do the job I’ve asked it to do. To protect your/your child’s health information, I require the business associate to appropriately safeguard your health information. Required by Law Under the law, I must make disclosures of your/your child’s PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization:
Abuse and Neglect
Judicial and Administrative Proceedings
Family Involvement in Care
Public Safety (Duty to Warn)
The following language addresses these categories to the extent consistent with the NASW Code of Ethics. Without Authorization Applicable law and ethical standards permit me to disclose information about you/your child without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)
Required by Court Order
Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Verbal Permission I may use or disclose your child’s information to family members that are directly involved in your/your child’s treatment with your verbal permission. With Authorization Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Revocation of Authorization If you provide me with permission to use or disclose PHI about you/your child, you may revoke that permission, in writing, at any time. If you revoke your authorization, I will no longer use or disclose medical information about you/your child for the purposes covered by the written authorization. However, I am unable to take back any disclosures that I have already made with your authorization. Your/Your Child’s Rights Regarding Your/Your Child’s PHI You have the following rights regarding PHI I maintain about you/your child. To exercise any of these rights, please submit your request in writing to me:
Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your/your child’s care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would be reasonably likely to endanger the life or physical safety of you, another person or your child. I may charge a reasonable, cost-based fee for copies. I will act on your request within thirty days of receiving your request.
Right to Amend. If you feel that the PHI I have about you/your child is incorrect or incomplete, you may ask me in writing to amend the information although I am not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures that I make of your child’s PHI. This is a list of certain disclosures I have made of your/your child’s PHI. To make this request, you should submit it in writing to me. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information I use or disclosure about your child for treatment, payment or health care operations. For example, you might request that particularly sensitive information (such as the existence of drug dependence) not be disclosed for any purpose. I am not required to agree to your request. To request restrictions, you must submit your request in writing to me. In your request, you must tell me (1) what information you want to limit, (2) whether you want to limit the use, disclosure, or both, and (3) to whom you want the limits to apply (for example, disclosures to your insurance carrier.)
Right to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail.
Right to a Copy of this Notice. You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time.
Complaints If you believe I have violated you or your child’s privacy rights, you have the right to file a complaint in writing with me or with the Office for Civil Rights, U.S. Department of Health and Human Services, Government Center, J.F. Kennedy Federal Building–Room 1875, Boston, Massachusetts 02203.
Voice phone (617) 565-1340
Fax (617) 565-3809
TDD (617) 565-1343
I will not retaliate against you for filing a complaint. The effective date of this Notice is January 2, 2008.
Client signature:____________________________________________ (including receipt of privacy information package)
Signature of parent/guardian:____________________________________________ (including receipt of privacy information package)
Date:___________________________________________________ Christina M. Strain, LICSW 18 Vining Hill Road Southwick, MA 01077 (860) 539-5369 _____________________________________________________________________ Authorization of Disclosure PolicyÂ Â Â Â Â Â Â Â Â Â Â Â Effective: January 2, 2008
Policy Except as expressly permitted by applicable law (as reflected in applicable policies), PHI shall not be used or disclosed without a valid authorization from the client . The term “authorization” as used in this policy means a form that meets all the requirements of the Privacy Standards. Procedure 1. Content of Authorization 1.1 A valid authorization will contain the following elements: 1.1.1 A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion 1.1.2 The specific name or other specific identification of the person(s), or class of persons, authorized to provide the information 1.1.3 The name or other specific identification of the person(s), or class of persons, or organization authorized to receive the information 1.1.4 A description of the purpose of the use or disclosure 1.1.5 An expiration date or an expiration event 1.1.6 Signature of the client and date (If a personal representative rather than the client/parent/guardian signs the authorization, the authorization must specify how the representative is authorized to act for the client.) 1.1.7 A statement about the client’s right to revoke the authorization in writing and the exceptions to the right to revoke and a description of how the individual may revoke the authorization. 1.1.8 A statement that Christina M. Strain may not refuse to treat the client if the client refuses to sign the authorization, except for the provision of research-related treatment or if the purpose of the treatment is solely to create PHI for disclosure to a third party (e.g., a fitness for duty evaluation) 1.1.9 A statement about the potential, if any, for the information to be re-disclosed by the recipient of the information and no longer be protected. Under Federal law, substance abuse treatment information may not be re-disclosed unless the client consents in writing to re-disclosure by the recipient of the information 1.2 The authorization may contain additional elements as long as they do not contradict the required elements. 2. Invalid Authorizations. An authorization is invalid if any of the following apply: 2.1 The expiration date has passed or the expiration event has occurred 2.2 A required element is not filled out completely 2.3 The authorization is known to have been revoked 2.4 The authorization conditions the provision of treatment on signing the authorization, unless otherwise permitted as described above 2.5 The authorization requires the client to waive his or her rights under the Privacy Standards as a condition of receiving treatment 2.6 The authorization is combined with any other document, except another authorization for use or disclosure of PHI 2.7 Any material information in the authorization is known by the Covered Entity to be false 3. Additional Requirements 3.1 The authorization must be written in plain language 3.2 Any authorization for use or disclosure of PHI that is signed by the client shall be retained in the patient/client’s record 3.3 A copy must be given to the client (except where the client furnishes the authorization form) 4. Compound and Multi-Party Authorizations 4.1 An authorization may be combined with another authorization to create a compound authorization except a) authorizations for use or disclosure of psychotherapy notes may be combined only with another authorization for psychotherapy notes and b) if one of the authorizations is conditional and the other is not, they may not be combined. 4.2 An authorization cannot be combined with any other type of document such as a notice of privacy practices except that a research authorization may be combined with any other type of written permission for the same research study 4.3 A multi-party authorization is permissible if the information to be disclosed and the purpose for the disclosure are the same for all parties. However, if the client revokes the authorization for one party, the entire multi-party authorization is revoked. 5. Effect of Prior Authorization. PHI that was created or received prior to January 2, 2008, may be used or disclosed based on an authorization that was signed prior to January 2, 2008 as long as the authorization is otherwise valid (e.g., not expired, addresses the disclosure). References 45
Christina M. Strain, LICSW
18 Vining Hill Road Southwick, MA 01077 (860) 539-5369 __________________________________________________________ Accounting of Disclosures Policy Â Â Â Â Â Â Â Effective: Jan. 2, 2008
Policy The client has the right to request a list of disclosures of the client’s PHI. Procedure 1. Requests for an accounting of disclosures must be made in writing and forwarded to Christina M. Strain. 2. Christina M. Strain is responsible for accounting for all disclosures. The following disclosures do not need to be included in the accounting: 2.1 Prior to January 2, 2008 2.2 To carry out treatment, payment or healthcare operations 2.3 To clients of their own PHI 2.4 Pursuant to an authorization 2.5 Incident to a use or disclosure otherwise permitted or required by the Privacy Standards 2.6 For facility directories 2.7 To a family member, or to any other person identified by the client, of information directly relevant to such person’s involvement with the client’s care; 2.8 To notify a family member or another person of the client’s location or general condition; 2.9 As part of a “limited data set” (as defined by the Privacy Standards) 2.10 To correctional institutions or law enforcement officials 2.11 For national security or intelligence 3. Disclosures of PHI that could have been made by a business associate must be included. 4. Upon receipt of a client request, an accounting of disclosures must be provided. The list of disclosures must include: 4.1 Date 4.2 Name and address of the person or entity who received the information 4.3 Brief description of the information disclosed 4.4 Purpose of the disclosure If multiple disclosures are made to the same person/entity for the same purpose, it is sufficient to list all required information for the first disclosure, and then specify the number or frequency of disclosures, and date of the last disclosure. 5. The request must be responded to within 60 days. However, if Christina M. Strain is unable to respond to the request in 60 days, the response time may be extended one time by up to 30 additional days. In this case, Christina M. Strain must notify the client within the original 60-day deadline of the date by which Christina M. Strain will respond to the request, and the reason for the delay. 6. The client is entitled to one accounting of disclosures without charge during any 12-month period. A reasonable cost-based fee may be charged for additional accountings. 7. If there are disclosures to a health oversight or law enforcement agency that must be accounted for, the client’s right to receive a listing of disclosures may be temporarily suspended upon request of the agency, for no more than 30 days. 8. Accounting of disclosures of PHI in the research context involves additional documentation. References 45 C.F.R. 164.528 45 C.F.R. 164.530(j) C.F.R. 164.508