Effective:  April 14, 2003

                       

HIPAA NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW MEDICAL AND PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY

 

If you have any questions about this notice, please contact Dr. Jessica Horsfall, (425) 761-8928

 

WHO WILL FOLLOW THIS NOTICE:

This notice describes the practice of Eastside Neuropsychology, PLLC

 

This Notice of Privacy Practices will tell you how we handle medical and psychological information about you and/or your child.  It tells how we use this information within the office, how we share it with other professionals and organizations, and how you can access this information.  This notice reflects federal laws under HIPAA, California state law, and ethical issues related to the field of clinical psychology.  Aspects of these domains that are not relevant to the work done within this office have not been included in this notice. If a use or disclosure of you or your child’s Protected Health Information (PHI) is prohibited or materially limited by other applicable law, our office will reflect the more “stringent law.”

 

The information we collect about you and your child is called Protected Health Information (PHI).  This information is kept in you or your child’s file or chart in our office or another secure storage facility. 

 

We are required by law to:

• Make sure that medical and psychological information that identifies you and or your child is kept private;

• Give you this notice of our legal duties and privacy practices with respect to medical and psychological information about you and/or your child; and

• Follow the terms of the notice that is currently in effect.

 

 

HOW WE MAY USE AND DISCLOSE MEDICAL AND PSYCHOLOGICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical and/or psychological information.  For each category of uses or disclosures we will explain what we mean and give at least one example.  All of the ways we are permitted to use and disclose information will fall within one of the categories.

 

• For Treatment:  We may use medical and/or psychological information to support you or your child’s treatment or services.  We may disclose such information about you or your child to other members of you or your child’s treatment team such as doctors, psychologists or occupational/physical therapists.

 

Examples of “Protected Health Information” (PHI) include:

• Developmental, medical, psychological, educational, school, vocational, family, and/or personal history

• Reasons for assessment or treatment, including problems, complaints, symptoms, or needs

• Diagnostic impressions or diagnoses. (“Diagnoses” are the medical terms for you or your child’s problems or symptoms).

• Treatment plans, including a list of treatments and any other services which we think would be appropriate to help you or your child.

• Progress notes (therapy patients only).

• Records from others who treated or evaluated you and/or your child

• Neuropsychological tests including raw data, summary sheets of scores, computerized scoring results

• Behavioral observations from testing

• Notes from conversations with other people that you have asked us to speak with regarding you or your child

• School records or other reports

• Information about medications you or your child took or are taking.

• Legal matters

• Neuropsychological or Educational Reports of Neuropsychological Assessment written by our office

• Billing Information

 

This list is not fully inclusive, but rather offers several examples of the kind of information included by the term “Protected Health Information.”

 

• For Payment:  We may, in given cases, use and disclose medical and/or psychological information (including treatment and services received) about you or your child.  This information will allow for billing and collection of payment from you, an insurance company, or a third party.  For example, we may need to provide your insurance company with the procedure code for services you received in order for you to receive coverage.

 

• For Health Care Operations:  We may use and disclose medical and/or psychological information about you or your child for operations within our office.  These uses and disclosures are necessary to perform psychological or neuropsychological tasks and to offer quality care.  For example, we may combine medical information about several patients to evaluate what additional services we should offer, and whether recommended treatments produce anticipated results.  Another example would be that clerical staff in the office may have access to you or your child’s test scores and so they can type the “Summary Sheet of Scores.”

 

• Appointment Reminders:  We may use and disclose medical and/or psychological information to contact you as a reminder that you have an appointment at our office.   

 

• Treatment Alternatives:  We may use and disclose medical and/or psychological information to tell you about or recommend possible treatment options or alternatives that may be of interest to you or your child.

 

• Research:  Under certain circumstances, we may use and disclose medical and/or psychological information about you or your child for research purposes.  All research projects, however, are subject to a special approval process that evaluates a proposed research project and its use of medical/psychological information in order to balance the research needs with patients’ need for privacy.  Before using information the project will have to be approved through this research approval process.  Additionally, before using data from you or your child’s test results, our office would first contact you to obtain written permission.

 

• Individuals Involved in Your or Your Child’s Care or Payment:  We may release medical and/or psychological information about you or your child to a friend or family member who is involved in the medical care.  We may also give information to someone who helps pay for your care.  In addition, we may disclose medical and psychological information about you or your child to an entity assisting in a disaster relief effort so that your family can be notified about you or your child’s condition, status and location.

 

• As Required by Law:  We will disclose medical/psychological information about you when required to do so by federal, state or local law.

 

• To Avert a Serious Threat to Health or Safety:  We may use and disclose medical and/or psychological information about you or your child when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only to be someone able to help prevent the threat.

 

SPECIAL SITUATIONS

• Military and Veteran:  If you are a member of the armed forces, we may release medical and/or psychological information about you as required by military command authorities.  We may also release medical and/or psychological information about foreign military personnel to the appropriate foreign military authority. 

 

• Workers’ Compensation:  We may release medical and/or psychological information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

 

• Public Health Risks:  We may disclose medical and/or psychological information about you or your child for public health activities.  These activities generally include the following:

 

• To prevent or control disease, injury or disability;

 

• To report the abuse or neglect of children, elders and dependent adults;

 

• To report reactions to medications or problems with products;

 

• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

 

• Health Oversight Activities:  We may disclose medical and/or psychological information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. 

 

• Lawsuits and Disputes:  If you are involved in a lawsuit or a dispute, we may disclose medical and/or psychological information about you in response to a court or administrative order.  We may also disclose medical and/or psychological information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

 

• Law Enforcement:  We may release medical/psychological information if asked to do so by a law enforcement official:

 

• In response to a court order, subpoena, warrant, summons or similar process

 

• To identify or locate a suspect, fugitive, material witness, or missing person

 

• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement

 

• About a death we believe may be the result of criminal conduct;

 

• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

 

• National Security and Intelligence Activities:  We may release medical and/or psychological information about you and/or your child to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

 

• Protective Services for the President and Others:  We may disclose medical and/or psychological information about you and your child to authorized federal officials so they may provide protection to the President, other authorized persons, foreign heads of state, or those who conduct special investigations.

 

• Inmates:  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical and/or psychological information about you to the correctional institution or law enforcement official.  This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

 

YOUR RIGHTS REGARDING MEDICAL AND PSYCHOLOGICAL INFORMATION ABOUT YOU AND/OR YOUR CHILD:

• Right to Inspect and Copy:  You have the right to inspect and copy medical and/or psychological information that may be used to make decisions about you or your child’s care.  Usually, this includes medical and billing records, but may not include some mental health information.

 

To inspect and copy medical and/or psychological information that may be used to make decisions about you or your child, you must submit your request in writing to Dr. Jessica Horsfall.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

 

We may deny your request to inspect and copy in certain limited circumstances.  If you are denied access to medical and/or psychological information, you may request that the denial be reviewed.  Another licensed health care professional will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

 

• Right to Amend:  If you feel that medical and/or psychological information about you or your child is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for the office.

 

To request an amendment, your request must be made in writing and submitted to Dr. Jessica Horsfall. In addition, you must provide a reason that supports your request.

 

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

           

• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

 

• is not part of the medical and/or psychological information kept by or for the office;

 

• is not part of the information which you would be permitted to inspect and copy; or

 

• is accurate and complete.

 

• Right to an Accounting of Disclosures:  You have the right to request an “accounting of disclosures.”  This is a list of the disclosures we made of medical and/or psychological information about you or your child other than our own uses for treatment, payment and health care operations, as those functions are described above.

 

To request this list of accounting of disclosures, you must submit your request in writing to Dr. Jessica Horsfall.  Your request must state a time period which may be no longer than six years and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper, electronically).  The first list you request within a 12-month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

 

• Right to Request Restrictions:  You have the right to request a restriction or limitation on the medical/psychological information we use or disclose about you or your child for treatment, payment or health care operations.  You also have the right to request a limit on the medical/psychological information we disclose about you or your child to someone who is involved in your care or the payment for your care, such as a family member or friend.

 

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

 

To request restrictions, you must make your request in writing to Dr. Jessica Horsfall.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

 

• Right to Request Confidential Communications:  You have the right to request that we communicate with you about medical/psychological matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.

 

To request confidential communications, you must make your request in writing to Dr. Jessica Horsfall.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.

 

• Right to a Paper Copy of This Notice:  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

 

To obtain a paper copy of this notice, contact Eastside Neuropsychology, PLLC at (425) 761-8928.

 

CHANGES TO THIS NOTICE:

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical/psychological information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in the office.  The notice will contain on the first page, in the top right-hand corner, the effective date.  In addition, each time you or your child is seen for a new evaluation or procedure, we will offer you a copy of the current notice in effect.

 

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services.  To file a complaint with our office, contact Dr. Jessica Horsfall, (425) 761-8928.  All complaints must be submitted in writing.

 

You will not be penalized for filing a complaint.

 

OTHER USES OF MEDICAL/PSYCHOLOGICAL INFORMATION:

Other uses and disclosures of medical and/or psychological information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical and/or psychological information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical and/or psychological information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

 

The effective date of this notice is April 14, 2003.