Notice of Privacy Practices

This federally mandated notice describes how psychological and medical information about you may be used and disclosed and how you can access this information.  Please review it carefully.

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

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.  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 I provide, coordinate, or manage your health care and other services related to your health care.  An example is consulting with another health care provider, such as your family physician or another therapist.
    • Payment is when I obtain reimbursement for your healthcare.  An example is disclosing your PHI to your health insurer to obtain reimbursement, or to determine eligibility or coverage.
    • Health Care Operations are activities that relate to the performance and operation of my practice.  Examples are quality assessment and improvement activities, audits and administrative services, and case management and care coordination.
  • “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your authorization is obtained.  “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 authorization from you before releasing this information.  I will also obtain authorization before releasing information from your psychotherapy notes.  “Psychotherapy notes” are notes about our private psychotherapy sessions, which are kept separate from the rest of your medical record.  These notes are afforded greater protection than PHI.

You may revoke all such authorizations of PHI or information from psychotherapy notes at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that (1) I 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.

Uses and Disclosures with Neither Consent or Authorization

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

  • Child Abuse – I am required to report PHI to the appropriate authorities when I have reasonable grounds to believe that a minor is or has been the victim of neglect, physical and/or sexual abuse.
  • Adult and Domestic Abuse – If I am responsible for the care of an incapacitated or vulnerable adult, I am required to disclose PHI when I have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult’s property has occurred.
  • Health Oversight Activities – If the Arizona Board of Behavioral Health Examiners is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena from the Board.
  • Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I 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.
  • Serious Threat to Health or Safety – If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures.  If I believe there is an imminent risk that you will inflict serious harm on yourself, I may disclose information in order to protect you.
  • Worker’s Compensation – I may disclose PHI 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.

Patient’s Rights and Therapist’s Duties

Patient’s Rights:

  • Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of PHI.  However, I am 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, if you request return phone calls at your work rather than home, then I will abide by your request.)
  • Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in my mental health and billing records for as long as the PHI is maintained in the record.  I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  At your request, I will discuss the details of the request and denial processes.
  • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  I may deny your request.  At your request, I will discuss the details of the amendment process.
  • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI.  At your request, I will discuss the details of the accounting process.
  • Right to a Paper Copy – You have the right to obtain a paper copy of this notice from me upon request, even if you have agreed to receive the notice electronically.

Therapist’s Duties:

  • I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
  • I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
  • I will notify you of revisions to my policies at our next scheduled appointment.  If there is no appointment scheduled, and the revision affects some intended use or disclosure of your PHI, I will notify you at the mailing address on record before making any such use or disclosure.

Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me by telephone at 928/308-2294 or by mail at 8430 E. Spouse Drive, Prescott Valley, AZ  86314.  If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me at the address above.  You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  I can provide you with the appropriate address upon request.  You have specific rights under the Privacy Rule.  I will not retaliate against you for exercising your right to file a complaint.

Effective Date, Restrictions, and Changes to Privacy Policy

This notice is effective as of April 14, 2003.

I will limit the uses or disclosures that I may make as follows:

Except as specified in Section III above, information regarding your psychotherapy will only be released with your consent or authorization.  Psychotherapy notes, themselves, will rarely, if ever, be released unless required by law.  Instead, pertinent information from psychotherapy notes will be summarized, with the intention of providing the minimum amount of information necessary to achieve the particular purpose.  Again, this will be done only at your request or as specified in Section III.

  • I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will notify you of revisions at our next scheduled appointment.  If there is no appointment scheduled, and the revision affects some intended use or disclosure of your PHI, I will notify you at the mailing address on record before making any such use or disclosure.
  • I find myself in my vulnerability
  • You can ask for everything
  • Willing to have the wound of Love
  • Exceptional experience is crucial
  • It’s only intensity
  • Tap into the flow of your awareness
  • If you don’t do conflict you do alienation
  • It’s complex and trivial
  • Individuality is all

Phone

Phone
(928) 848-1111
Email
info@azgestaltinstitute.com

Street

Address
3259 N. Wisdom Way
Prescott, AZ 86305

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