Notice of Privacy Practices

Because of the nature of the types of issues, problems and difficulties persons commonly bring to psychotherapy, Dr. Geysen understandably feels very strongly about providing services in a discrete, private and confidential arrangement. He strives diligently to offer a safe and healing environment for persons and is very concerned about preserving the trust of persons by protecting the security of the information and material shared with him.

When providing services to clients, psychotherapists need to consider issues such as informed consent, patient confidentiality and duty to warn. Informed consent involves notifying a client of all of the potentials risks and costs associated with treatment. This includes explaining the exact nature of the treatment, any possible risks and the available alternatives.

Because clients frequently discuss issues that are highly personal and sensitive in nature, psychotherapists have a legal obligation to protect a patient’s right to confidentiality. However, one instance where psychotherapists have a right to breach patient confidentiality is if clients pose an imminent threat to either themselves or others. Duty to warn gives counselors and therapists the right to breach confidentiality if a client poses a risk to another person.

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please take the time to review it carefully.

Uses and disclosures of protected information

With your consent, we may use and disclose protected health information (PHI) about you for treatment, to obtain payment, and for healthcare operations (i.e., activities related to operations and performance of the practice such as audits, administrative services, case management, and care coordination). Because continuity of care is part of treatment, your PHI may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. We may use or disclose identifiable health information about you without your written authorization in several situations, but beyond these situations we will ask for your written authorization before disclosing any identifiable health information about you.

Uses and disclosures requiring authorization

We may disclose PHI for purposes outside of treatment, payment, or healthcare administration with your authorization. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. If we are asked for information outside of treatment, payment, or health care operations, we will ask for your authorization. We will also need to obtain an authorization before releasing psychotherapy notes which are considered separate from the rest of you clinical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations at any time but the revocation must be in writing. You may not revoke an authorization to the extent that (1) we have relied on it, or (2) if it was given as a condition of obtaining insurance coverage, the law provides the insurer the right to contest the claim under the policy.

Uses & disclosures without your authorization

We may use or disclose PHI without your consent, opportunity to object, or authorization under the following circumstances:

• Child abuse and neglect. If in the course of our professional activities, we form suspicions that a child under the age of 18 has been abused or neglected, we must report this suspicion or belief to the appropriate authority.Adult and domestic abuse victims. If we know or suspect that a person who is elderly, disabled, or incompetent has been abused, we may disclose the appropriate information as permitted by law.Health oversight activities & compliance. If a health regulatory agency is investigating or inspecting us, we may disclose records subpoenaed relevant to the investigation.Judicial & administrative procedures. If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we 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 & safety. If we believe in good faith that there is risk of imminent personal injury to you or other individuals or risk of imminent injury to the property of other individuals, we may disclose the appropriate information as permitted law.

  Workers Compensation. We may disclose information when authorized and necessary to comply with laws relating to Workers Compensation or other similar programs.

  Your rights

  The health and billing records we create are the property of this practice. Generally, the protected information in our records is available to you.

  Here are your rights:

  Right to request restrictions on disclosures. You have the right to request us not to use or disclose certain parts of your PHI for treatment, payment, or healthcare operations. However, we are not required to agree to a restriction you request. You may also request that information not be disclosed to family members. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, but if we do agree, then we will follow it.

  Right to request confidential communications from us by alternative means and at alternative locations. You have the right to request and receive confidential communications of PHI in a certain way and at a certain location. (For example, you may not want a family member to know that you are being seen here and wish to be contacted at work.) The request must be in writing. On your written request, we will send your bills and other information to another address. We will accommodate reasonable requests. You do not need to explain the basis of your request.

  Right to inspect and copy. You have the right to inspect or obtain a copy of PHI in your mental health and billing records for as long as we maintain your PHI in the record. Our current copying fee is $.50 per page with a minimum charge of $5. We may deny you 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.

  Right to amend. You have the right to request that we amend your PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process. Your statement will be included with any record release.

  Right to an accounting of disclosures. You generally have the right to request an accounting of disclosures of PHI made for purposes other than for treatment, payment, or healthcare operations. On your request, we will discuss with you the details of the accounting process. You may receive this listing once every 12 months without charge. There will be a fee for additional requests.

  Right to a copy of this notice. You may request a copy of this notice at any time.

  Our responsibility

  Psychologists are required by law to maintain your privacy and to provide you with this notice of our duties and privacy practices with respect to PHI.

  Changes in our privacy policies

  We have 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 in a significant manner, we will provide you with a new notice, in person or by mail, or by posting it in our waiting area for at least 15 days.

  Complaints

  If you are concerned we may have violated your privacy rights, or disagree with a decision we made about access to your records, you may first contact Dr. Geysen at 860 633-0703. He will try to resolve the matter. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

  Effective date

  This notice will go into effect on April 14, 2003.

  Additional information: terminology

  To help clarify terms used in this notice, here are some definitions:

  PHI refers to information in your health record that could identify you.

  Use applies only to activities within this practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

  Disclosure applies to activities outside of this practice such as releasing, transferring, or providing access to information about you to other parties.

  Treatment, Payment and Health Care Operations

  Treatment occurs when a psychologist provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when a psychologist consults with another health care provider, such as your family physician or another psychologist.

  Payment activities occur when we attempt to obtain reimbursement for services related to 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.

  Healthcare Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment, staff performance, improvement activities, and business-related matters such as audits and administrative services, and case management and care coordination.

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  © ChangePoint, LLC, 2006

  Effective September 1, 2015