Village
Counseling Services
Notice
of Privacy Practices
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED, AS WELL AS HOW YOU MAY GAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY, AND SIGN THE ACKNOWLEDGEMENT OF
RECEIPT.
Protecting Your
Personal and Health Information
Village Counseling Services is committed to protecting
the privacy of client personal and health information. Applicable Federal and
State laws require us to maintain the privacy of our clients’ personal and
health information. This Notice explains our privacy practices, our legal
duties, and your rights concerning your personal and health information. In
this Notice, your personal or protected health information (PHI) is referred to
as “health information” and includes information regarding your health care and
treatment with identifiable factors such as your name, age, address, income or
other financial information. We will follow the privacy practices described in
this Notice while it is in effect. This Notice takes effect July 13, 2006 and
will remain in effect until replaced.
How We Protect Your
Health Information
We protect your health information by:
Uses and Disclosures for Treatment, Payment, and
Health Care Operations
Village Counseling Services may use or disclose
your protected health information (PHI), for treatment, payment,
and health care operations purposes, as long as you have given your consent
to receive evaluation or treatment services from Village Counseling Services. To
help clarify these terms, here are some definitions:
Treatment, Payment, and
Health Care Operations:
Treatment - when an office provides, coordinates,
or manages your health care and other services
related to your health care. An example of treatment would be when an office consults with another health
care provider, such as your family physician. Payment is when you provide reimbursement for the services you
receive in the office. Health Care Operations are
activities that relate to the performance and operation of the office. Examples of health care operations are
quality assessment and improvement activities, business-related matters such as
audits and administrative services, case management and care coordination, conducting training and
educational programs or accreditation
activities.
Use -
activities within the office such as sharing, employing,
applying, utilizing, examining, and analyzing information that identifies you.
Disclosure - activities outside of the office, such as releasing,
transferring, or providing access to information about you to other parties.
Uses and Disclosures Requiring Authorization
Village Counseling Services may use or disclose PHI
for purposes outside treatment, payment, or healthcare operations when your
authorization is obtained. An “authorization” is written permission
above and beyond the general consent that permits only specific disclosures. In
those instances when the office is asked for information for purposes outside
of treatment, payment or healthcare operations, we will obtain an authorization
from you before releasing this information.
You may revoke all such authorizations at any time,
provided each revocation is in writing. You may not revoke an authorization to
the extent that the office has relied on that authorization to provide your
services.
Uses and
Disclosures with Neither Consent nor Authorization
Village Counseling Services may use or disclose PHI
without your consent or authorization in the following circumstances:
·
Abuse - If we have
reason to believe that a minor child, elderly person or disabled person has
been abused, abandoned, or neglected, the office must report this concern or observations
related to these conditions or circumstances to the appropriate authorities.
·
Health Oversight Activities - If the Texas State Board of Examiners of Professional
Counselors or other licensing or accrediting body is investigating an office
that you have filed a formal complaint against, the office may be required to
disclose protected health information regarding your case.
·
Judicial and Administrative Proceedings as Required - If you are involved in a court proceeding and a court
subpoenas information about the professional services provided you and/or the
records thereof, we may be compelled to provide the information. Although courts have recognized a
therapist-client privilege, there may be circumstances in which a court would
order the office to disclose personal health or treatment information. The
office will not release information unless we have written authorization from
you or your legally appointed representative; the office will release
information if we are presented with a court order. The privilege does not
apply when you are being evaluated for a third party (e.g. Law enforcement
agency or Social Security) or where the evaluation is court ordered.
·
Serious Threat to Health or
Safety - If you communicate
to office personnel an explicit threat of imminent serious physical harm or
death to identifiable victim(s), and we believe you may act on the threat, we
have a legal duty to take the appropriate measures to prevent harm to that
person(s) including disclosing information to the police and warning the
victim. If we have reason to believe that you present a serious risk of physical
harm or death to yourself, we may need to disclose information in order to protect
you. In both cases, we will only disclose what we feel is the minimum amount of
information necessary.
·
Worker’s Compensation - The office may disclose protected health information regarding
you 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.
·
National Security - We may
be required to disclose to military authorities the health information of Armed
Forces personnel under certain circumstances. We may be required to disclose to
authorized federal officials health information
required for lawful intelligence, counterintelligence, and other national
security activities. We may be required to disclose health information to a
correctional institution or law enforcement official having lawful custody of
protected health information of an inmate or patient under certain
circumstances.
·
Research - Under certain limited circumstances, we may use and
disclose health information for research purposes. Your authorization will be
secured for these uses/disclosures of your information.
Client Rights and
Psychologist’s Duties
Client Rights:
·
Rights to Request
Restrictions
- You have the right to request additional restrictions on certain
uses and disclosures of protected health information (PHI). Village Counseling
Services may not be able to accept your request, but if we do, we will uphold the
restriction unless it is an emergency.
·
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 being seen at this office. On your request, the office will communicate with you at
another address.)
·
Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both)
of your records. A reasonable fee may be charged for copying. Access to your records
may be limited or denied under certain circumstances, but in most cases you
have a right to request a review of that decision. 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 in writing an amendment of
your health information for as long as PHI records are maintained. The request
must identify which information is incorrect and include an explanation of why
you think it should be amended. If the request is denied, a written explanation
stating why will be provided to you. You may also make a statement disagreeing
with the denial, which will be added to the information of the original
request. If your original request is approved, we will make a reasonable effort
to include the amended information in future disclosures. Amending a record
does not mean that any portion of your health information will be deleted.
·
Right to an Accounting - You generally have
the right to receive an accounting of disclosures of PHI. If your health
information is disclosed for any reason other than treatment, payment, or
operation, you have the right to an accounting for each disclosure of the previous
six (6) years. The accounting will include the date, name of person or entity,
description of the information disclosed, the reason
for disclosure, and other applicable information. If more than one (1)
accounting is requested in a twelve (12) month period, a reasonable fee may be
charged.
·
Electronic vs. Paper Copy - If you received this notice electronically (e.g.,
accessing a website), you have the right to obtain a paper copy of the notice
from the office upon request.
Village Counseling
Services Duties:
Other Restrictions
Changes to this
Notice
Village Counseling Services reserves the right to
change our privacy practices and terms of this Notice at any time, as permitted
by applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information
that we maintain, including health information we created or received before we
made the changes. Before we make such changes, we will update this Notice and
post the changes in the Office waiting room. You may request a copy of the
Notice at any time.
Questions and
Complaints
For questions regarding this Notice or our privacy
practices, or if you are concerned that your privacy rights may have been
violated, please contact your therapist.
You may also make a written complaint to the U.S. Department of Health
and Human Services whose address can be provided upon request. If you choose to
make a complaint with the U.S. Department of Health and Human Services, or with
us we will not retaliate in any way.
Village Counseling Services
Telephone: 713-533-9811
Access
and Amendment Policy
Access Right
We give clients access to their health information whether
we or our business associates hold that information and whether or not we were
the source of the information. Exceptions to this access occur rarely, such as
when disclosure of the information to the individual is deemed dangerous. If we
feel we need to deny access, we provide an explanation. Sometimes the client
can contest this denial, and then we will have a third party review the
situation. The client must request access in writing, and we will record the
request in a log book. We typically have 30 days in which to provide the
information. We will charge the patient the cost of photocopying.
Amendment Right
The client must request in writing that we amend our
records about the client. We will log the patient client and reply within 60
days. We may deny the client request, if we were not the originators of the
information or we believe the information is accurate.
When we make an amendment, we add a note to the record to
indicate the change but do not delete the original information. If we deny the
client request, then we provide an explanation to the client and in the record.
The client may contest our denial and among other things we will document the
client concerns in the record.
Accounting
and Restrictions Policy
Accounting of Disclosures
The client has a right to receive an accounting of certain
disclosures of the client’s protected health information. The client’s request
must be in writing. We have 60 days to respond.
Our accounting to the client will:
• Be in writing,
• Include the dates of disclosure and to whom the
information was sent,
• Describe what information was sent, and
• State the purpose of the disclosure.
Not subject to the accounting requirement are disclosures:
• made to the individual
• for treatment, payment, or health
care operations,
• made with client authorization,
• covered by a business associate agreement,
• for national security or
intelligence purposes, or
• to correctional institutions or
law enforcement officials.
Disclosures remaining in the ‘Notice of Privacy Practices’
under the heading ‘Without Opportunity to Object’ need to be tracked, and those
are disclosures for Public Health, Health Oversight, Abuse or Neglect, Food and
Drug Administration, Legal Proceedings, Coroners, Research, Workers’ Compensation,
or Compliance. In any given 12-month period, we will provide one accounting at
no cost. The accounting only covers disclosures since Privacy Rule Compliance
was required.
Restrictions on Use and Disclosure
The client may request restrictions on our use or
disclosure of the client’s protected health information beyond those
restrictions already imposed by the government. We may elect to accept the
restriction or not. However, if we accept the request, then we must abide by it
and could only reverse our position after notifying the client appropriately
first.
Restrictions on Communication Method
We will accommodate a request that we communicate with the
client by alternative means, if we can reasonably and practically implement
such an alternative. The client is not required to explain why he or she wants
such an alternative means of communication. Our agreement with the client for
an alternative communication channel will be documented and included in the client’s
medical record.
Consent
for the Use or Disclosure of Health Information for Treatment, Payment, or
Health Care Operations
In our Notice of Privacy
Practices, we provide you information about how Village Counseling Services can
use or disclose your mental health and medical information. As described in our
Notice of Privacy Practices, we request your consent for any use or disclosure
of mental health and medical information to carry out treatment, payment or
health care operations. You have a right to review our Notice of Privacy
Practices before signing this Consent form.
By signing this Consent
form, you: (1) Acknowledge that a copy of the Notice of Privacy Practices has
been provided to you; and (2) Consent to our use and disclosure of your health
information for treatment, payment or health care operations, as described in
the Notice of Privacy Practices.
You have the right to
revoke this Consent in writing at any time, except where we have already used
or disclosed your health information in reliance upon this Consent.
__________________________________________ __________________
Signature of Client or Legal Representative Date
______________________________________
Patient's Name (Printed) Date
--------------------------------------------------------------------------------------------------------------------------------------
Documentation of Good Faith Effort
Check
the applicable box showing Good Faith Effort.
˙
Emergency situation Provide patient with copy of NPP
as soon as reasonably practicable after the emergency treatment situation.
˙
Patient/Legal representative given NPP, but declines to
acknowledge receipt.
˙ Patient/Legal
Representative states that they have already received the NPP.
˙ Other ________________________________________________________________________
____________________________ __________
Staff Member (Signature) Date
___________________________
Staff Member (Printed)