Confidentiality and Privacy

Cover Letter
HIPAA Notice
Service Agreement

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This Notice Describes How Medical Information About You May be Used and Disclosed and How You Can Get Access to This Information. Please Review it Carefully.

Our Commitment to Your Privacy

Franco Psychological Associates (FPA) is dedicated to maintaining the privacy of your Personal Health Information (PHI). As required by the Health Insurance Portability and Accountability Act ("HIPAA,") we have prepared this explanation (Notice) of how we are required to maintain the privacy of and how we may use and disclose your personal health information.

1. Consent

With your consent (as documented on the attached service agreement) we may "use" your protected health information (PHI) within our practice, for treatment, payment, and health care operation purposes. In all cases, we will share only the minimum amount of information necessary to conduct the activity.

- Treatment involves providing, coordinating, or planning your health care. (for example when we consult with another therapist on our staff regarding the most effective plan of treatment).

- Payment uses involve disclosure of 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, such as measures of treatment effectiveness, patient satisfaction, and appointment reminders.



Authorization
We will only "disclose" the minimum necessary PHI for purposes other than treatment, payment, and health care operations noted above when your appropriate prior written authorization is obtained. This authorization will identify the specific information you wish to disclose, the specific identity of the person(s) to whom the information is to be disclosed, and the purpose. Our psychotherapy notes, which may describe some of the content of your sessions, will only be disclosed with your specific authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
  
Uses and Disclosures Without Authorization
We may be required to disclose PHI without your authorization to preserve life, protect persons from immediate harm, or to refer you to a more appropriate level of care when there is:
• Suspected Child Abuse: We are mandated by Pennsylvania Child Protective Services Law (Act 179, effective 5/28/07) to report suspected physical and sexual abuse of a child who is known to be a client of FPA, P.C. under the age of 18 years of age, and we must report this information to the Department of Public Welfare. In addition, we are mandated to report if we learn that a child under 13 years old has had sexual relationships OR if a child 13, 14, or 15 years old has had sexual relationships with a person who is 4 or more years older than her or him.
• Older Adult and Domestic Abuse: If we believe that an adult is in need of protective services (regarding abuse or neglect) we may need to report such to the local agency which provides protective services.
• Serious Threat to Health or Safety: If you express a serious threat to kill or seriously injure a readily identifiable person, including yourself or others, and we determine that you are likely to carry out the threat, we are mandated to take reasonable measures to prevent harm to you or others. This may include directly advising the potential victim of the threat or referring you to a higher level of care .
We may also be required to disclose PHI without your consent or authorization for the following specific legal reasons. However, we will attempt to obtain your prior written authorization before releasing this information.
• If you are involved in a court proceeding and a judge issues a court order to release your records (not simply a subpoena from an attorney).
• If you file a worker's compensation claim, we will be required to file periodic reports with your employer, which shall include, where pertinent, history, diagnosis, treatment, and prognosis.
 
 

Patient's Rights – You Have the Right to:


• Receive Confidential Communications by Alternative Means and at Alternative Locations – For example, you may not want a family member to know that you are receiving services here. Upon your written request, we will send your bills to another address.
• Request Restrictions – on certain uses and disclosures of PHI about you. However, we are not required to agree to a restriction you request. Your request should be made in writing to the Privacy Officer.
• Inspect, Copy, and Amend – your PHI in our mental health and billing records upon your written request. In some unusual situations you may not be permitted to see all of the record, but we will discuss the details of this process with you.
• An Accounting – of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice), upon your written request.
 


Complaints
You have the right to file a written complaint with Rebekah L. Feeser, Ph.D., Privacy Officer, at 26 State Ave., Carlisle, PA 17015, or the U.S. Department of Health and Human Services, Office of Civil Rights (1-877-696-6775), if you feel that your privacy protections have been violated.
 

I have read and understood the above notification

________________________________________     __________
Signature of Patient/Guardian   Date

I have been offered a copy of the Notice Form and Have ___accepted or ___declined

OFFICE USE ONLY: I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

______   _______   ______________________________
Date        Initials         Reason

Revised HIPAA Notice 1/2010