THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL, SPEECH AND LANGUAGE/AUDIOLOGY AND /OR 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 We 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” 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 health care provider. • “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 the clinic such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. • “Disclosure” applies to activities outside of the clinic such as releasing, transferring, or providing access to information about you to other parties. • “Authorization” is your written permission to disclose confidential health information. All authorizations to disclose must be on a specific legally required form. II. Other 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. 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. You may revoke all such authorizations 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, law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures without Authorization We may use or disclose PHI amongst the professional and administrative staff of The Loyola Clinical Centers without your consent or authorization. Similarly, we may use or disclose PHI without your consent or authorization in the following circumstances: • Child Abuse – If we have reason to believe that a child has been subjected to abuse or neglect, we must report this belief to the appropriate authorities. • Vulnerable Adult (including Vulnerable Elderly) Abuse – If we have reason to believe that a vulnerable adult has been subjected to abuse, neglect, self-neglect, or exploitation, we must report this belief to the appropriate authorities. • Health Oversight Activities – If we receive a subpoena from the Maryland Board of Examiners of Psychologists or the U. S. Department for Health and Human Services Office for Civil Rights because they are investigating our practice, we must disclose any PHI requested by them. • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and we will not release information without your written authorization or a court order. The privilege does not apply when 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 a specific threat of imminent harm against another individual or if we believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm. • Research – Our practice may use and disclose PHI for research purposes. Personal data will be adequately encoded to ensure your privacy and anonymity. IV. Patient’s Rights and Clinician’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. However, we are not required to agree to a restriction you 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 us. On your request, we 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 PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. 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 for PHI. • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. However, we are not required to grant this request as stated. On your request, we will discuss with you the details of the amendment process. • Right to an Accounting – You have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process. • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request.
Clinician’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 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, we will post notification in the waiting area. V. Questions and Complaints If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact Ms. Toi Carter, Privacy Officer, on (410) 617-2699. If you believe that your privacy rights have been violated and wish to file a complaint, you may do so by sending your written complaint to Ms. Toi Carter at the following address:
Loyola College In Maryland
Human Resources Department
4501 North Charles Street
Baltimore, Maryland 21210-2699 You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services Office for Civil Rights. Ms. Toi Carter can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. As such, we will not retaliate against you for exercising your right to file a complaint. VI. Effective Date, Restrictions, and Changes to Privacy Policy This notice will go into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will post notice of a revision in our waiting room and provide you with a copy, if requested.
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