Notice of Psychologist’s Policies and Practices to Protect the Privacy of

Your Health Information





I.  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 written authorization.  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 of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

Payment is when I obtain reimbursement for your healthcare.  Examples of payment are when I 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 my 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 my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

·         Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

·         Authorization” is your written permission to disclose confidential mental health information.  All authorizations to disclose must be on a specific legally required form. 

II.  Other Uses and Disclosures Requiring Authorization


I 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 I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information.   I will also need to obtain an authorization before releasing your Psychotherapy Notes.   “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record.  These notes are given a greater degree of protection than PHI.


You may revoke all such authorizations (of PHI or 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.


III.  Uses and Disclosures without Authorization


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


·         Child Abuse – If I know or have reasonable cause to suspect that a child known to me in my professional capacity has been or is in immediate danger of being a mentally or physically abused or neglected, I must immediately report such knowledge or suspicion to the appropriate authority.


·         Adult and Domestic Abuse – If I believe that an adult is in need of protective services because of abuse or neglect by another person, I must immediately report this belief to the appropriate authorities.


·         Health Oversight Activities – If the MA Board of Psychology is investigating me or my practice, I may be required to disclose PHI to 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 Massachusetts 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 if this is the case.


·         Serious Threat to Health or Safety – If I believe disclosure of PHI is necessary to protect you or another individual from a substantial risk of imminent and serious physical injury, I may disclose the PHI to the appropriate individuals.


·         Worker’s Compensation – If I am treating you for Worker’s Compensation purposes, I must provide periodic progress reports, treatment records, and bills upon request to you, the Office of Hearings and Adjudication, your employer, or your insurer, or their representatives.

IV.  Patient’s Rights and Psychologist'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, 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, you may not want a family member to know that you are seeing me.  On your request, I 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.  I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  You may be denied access to Psychotherapy Notes if I believe that a limitation of access is necessary to protect you from a substantial risk of imminent psychological impairment or to protect you or another individual from a substantial risk of imminent and serious physical injury.  I shall notify you or your representative if I do not grant complete access.  On your request, I will discuss with you the details of the request and denial process.  

·         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.  On your request, I will discuss with you the details of the amendment process.

·         Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI.  On your request, I 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 me upon request, even if you have agreed to receive the notice electronically.

·         Right to be notified if There is a Breach of Your Unsecured PHI – You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

·         You, the client, must sign an authorization before I can release your PHI for any uses and disclosures not described elsewhere in this Privacy Notice.

·         Right to Restrict Disclosures When You Have Paid for Your Care Out-Of-Pocket

You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

Psychologist’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.

·         If the psychologist intends to revise his/her policies and procedures, he/she must describe in the notice to patients how the psychologist will provide patients with a revised notice of privacy policies and procedures (e.g., by mail, e-mail).


V.  Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact the Massachusetts Board of Psychology.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on September 23, 2014.  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.