The following is APC’s Privacy Notification for Individuals Receiving Services.
WISCONSIN NOTICE FORM—Updated 9/23/13
Notice of Health Care Service Provider Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW HEALTH CARE, PSYCHOLOGICAL, AND 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
APC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with yourconsent. 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 APC provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when APC consults with another health care provider, such as your family physician or another psychologist.
- Payment is when APC obtains reimbursement for your healthcare. Examples of payment are when APC discloses 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 APC’s 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 APC [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
- “Disclosure” applies to activities outside of APC [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
APC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when APC is asked for information for purposes outside of treatment, payment and health care operations, APC will obtain an authorization from you before releasing this information.
APC will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes APC clinicians have made about conversations during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. **Please note that APC Care Coordinators do not conduct psychotherapy or counseling sessions. Notes generated by Care Coordinators are for the purpose of coordination of care, not treatment. Therefore, these notes are not considered “psychotherapy notes.”
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) APC has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
APC may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse: If APC has reasonable cause to suspect that a child seen in the course of professional duties has been abused or neglected, or have reason to believe that a child seen in the course of professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, APC must report this to the relevant county department, child welfare agency, police, or sheriff’s department.
- Adult and Domestic Abuse: If APC believes that an elder person has been abused, or neglected, APC may report such information to the relevant county department or state official of the long-term care ombudsman.
- Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that APC release records to them in order for the Psychology Examining Board to investigate a complaint, APC must comply with such a request.
- Judicial or administrative proceedings: 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 APC will not release the information without written authorization from you or your personal or 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 APC has reason to believe, exercising professional care and skill, that you may cause harm to yourself or another, APC must warn the third party and/or take steps to protect you, which may include instituting commitment proceedings.
- Worker’s Compensation: If you file a worker’s compensation claim, APC may be required to release records relevant to that claim to your employer or its insurer and may be required to testify.
IV. Client’s Rights and Health Care Provider’s Duties
- Right to Request Restrictions–You have the right to request restrictions on certain uses and disclosures of protected health information about you. You have the right to restrict disclosure of PHI to a health plan with respect to health care for which you have paid out-of pocket and in full. However, APC is not required to agree to all restrictions 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. Upon your request, APC 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. On your request, APC will discuss with you the details of the request 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. APC may deny your request. On your request, APC 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 regarding you. On your request, APC 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 Electronic Copy—You have the right to request and receive a copy of your PHI if stored electronically in a designated record set.
- Right to Timely Response—You have the right to receive your PHI in 30 or fewer days after we receive your request, whether in a paper or electronic format. APC may request one 30-day extension to provide your PHI, but will give you notice if this occurs.
- Right to Prohibit Sale of PHI—You have the right to prohibit the sale of your PHI without your express written authorization.
- Right to Opt Out—You have the right to opt out of receiving any fundraising communications from APC. (Please note: APC currently does not sell your PHI or use your PHI for fundraising communications.)
- Right to Notification of Breach—You have a right to be notified if there is a breach of unsecured PHI.R
- Right to Reasonable Fee—You have a right to receive your PHI information, but may be charged a reasonable, cost-based fee to cover costs of copying or labor to compile, scan, etc. records. See APC Fee and Service Policy for rates
Health Care Provider’s Duties:
- APC is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
- APC reserves the right to change the privacy policies and practices described in this notice. Unless APC notifies you of such changes, however, APC is required to abide by the terms currently in effect.
- If APC revises its policies and procedures, APC will provide individuals with a revised notice.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision APC makes about access to your records, or have other concerns about your privacy rights, you may contact Karen T. Drexler (414) 358-7146. If you believe that your privacy rights have been violated and wish to file a complaint with APC, you may send your written complaint Karen T. Drexler, 10045 W. Lisbon Ave. Wauwatosa, Wisconsin 53222.
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.
You have specific rights under the Privacy Rule. APC will not retaliate against you for exercising your right to file a complaint.
This notice will go into effect on September 23, 2013. APC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. APC will provide you with a revised notice.