Nathaniel Smith, Licensed Professional Counselor
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 REVIEW IT CAREFULLY, AND SIGN THE ACKNOWLEDGEMENT OF
RECEIPT.
Nathaniel Smith, LPC (“Counselor”) is committed to protecting the privacy of client personal and health information. Applicable Federal and State laws require that I maintain the privacy of clients’ protected health information (“PHI”) and that I provide you with this Notice to explain my privacy practices, legal duties, and your rights concerning your privacy.
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. I will
follow the privacy practices described in this Notice while it is in effect.
This Notice takes effect December 1, 2005 and will remain in effect until
replaced.
I protect
your health information by:
1.
Treating
all of your health information that I collect as confidential. (For exceptions
to confidentiality, please see Sections B-D below).
2.
Restricting
access to your health information only to those staff members who need to know
your health information in order to facilitate my services to you.
3.
Only
disclosing the minimum of your health information necessary for an outside
service company to perform its function on my behalf; such companies have by
contract agreed to protect and maintain the confidentiality of your health
information.
4.
Maintaining
physical, electronic, and procedural safeguards to comply with federal and
state regulations guarding your health information.
B. 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, as long as
you have given your consent to receive evaluation or treatment services from
me. To help clarify these terms,
here are some definitions:
1. “Treatment,
Payment, and Health Care Operations” Treatment is when a clinician provides,
coordinates, or manages your health care and other services related to your
health care. An example of treatment would be when I consult with your treating
physician or psychiatrist to coordinate your care.
2. “Payment”
is when you provide reimbursement for the services you receive from me.
3. “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, case
management and care coordination, conducting training and educational programs
or accreditation activities.
4. “Use”
applies only to activities within my practice, such as sharing, employing,
applying, utilizing, examining, and analyzing information that identifies you.
5. “Disclosure”
applies to activities outside of the Clinic, such as releasing, transferring,
or providing access to information about you to other parties.
I 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 I am asked for information
for purposes outside of treatment, payment or healthcare operations, I will
generally 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 I have relied on that authorization
to provide your services. Records
pertaining to couples and families seeking joint treatment will not be released
without authorization from all adults participating in the sessions.
I may use
or disclose PHI without your consent or authorization in the following
circumstances:
1. Abuse – If I have reason to believe that a minor child, elderly person or disabled person has been abused, abandoned, or neglected, I must report this concern or observations related to these conditions or circumstances to the appropriate authorities.
2. Health
Oversight Activities – If the Texas State Board of Examiners for
Professional Counselors or other licensing or accrediting body is investigating
a clinician that you have filed a formal complaint against, I may be required
to disclose protected health information regarding your case.
3.
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, I 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 me to disclose personal health or
treatment information. I will not release information unless I have written
authorization from you or your legally appointed representative or a valid and
binding order from a court of competent jurisdiction. However, 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.
5.
Serious
Threat to Health or Safety – If you communicate to me or any personnel working for me an
explicit threat of imminent serious physical harm or death to identifiable
victim(s), and I 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 I have reason
to believe that you present a serious risk of physical harm or death to
yourself or others, I may need to disclose information in order to protect you.
In either case, I will only disclose what I feel is the minimum amount of
information necessary.
6.
To notify
emergency response personnel about a possible exposure to AIDS or HIV.
7.
Worker’s
Compensation – I
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.
8.
National
Security- I may be
required to disclose to military authorities the health information of Armed
Forces personnel under certain circumstances. I may be required to disclose to
authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security activities. I
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.
9.
Required
by Law-As otherwise
required by federal, state or local law, judicial board or administrative proceedings,
or by law enforcement officials with written authority such as a valid and
binding court order or warrant.
1.
Client Rights:
A. Right to Request Restrictions – You have the right to request
additional restrictions on certain uses and disclosures of protected health
information (PHI). I may not be able to accept your request, but if I do, I
will uphold the restriction unless it is an emergency.
B. 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 by me. On your request, I
will communicate with you at another address.)
C. 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, I
will discuss with you the details of the request and denial process.
D. 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, I 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.
E. 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. The list
will not include uses or disclosures to which you have already consented, i.e.,
those for treatment, payment, or health care operations, sent directly to you,
or to your family; neither will the list include disclosures made for national
security purposes, to corrections or law enforcement personnel, or disclosures
made before April 15, 2003. After April 15, 2003, disclosure records will
be held for six years. I will respond
to your request for an accounting of disclosures within 60 days of receiving
your request. The list I give you will include disclosures made in the previous
six years (the first six year period being 2003-2009) unless you indicate a
shorter period. The list will include the date of the disclosure, to whom PHI
was disclosed (including their address, if known), a description of the
information disclosed, and the reason for the disclosure. I will provide the
list to you at no cost, unless you make more than one request in the same year,
in which case I will charge you a reasonable sum based on a set fee for each
additional request.
F. 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 upon request.
2.
Changes to this Notice:
I
reserve the right to change privacy practices and terms of this Notice at any
time, as permitted by applicable law. I reserve the right to make the changes
in privacy practices and the new terms of any 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 waiting room. You may request a
copy of the Notice at any time.
3.
Questions and Complaints:
For
questions regarding this Notice or my privacy practices, please contact
Nathaniel Smith directly at 214-205-0237.
If
you are concerned that your privacy rights may have been violated, you may
contact Nathaniel Smith at 214-205-0237 or you may also make a written
complaint to the U.S. Department of Health and Human Services at 200
Independence Avenue S.W. Washington, D.C. 20201whose address can be provided upon request. If you
choose to make a complaint to the U.S. Department of Health and Human Services,
or to me directly, I will not retaliate in any way.
I acknowledge I have received the Notice of Privacy
Practices of Nathaniel Smith, LPC.
Patient / Patient Representative Name:
______________________________________________
(Printed Name)
Signature: _____________________________________
Date: _________________________________________
If it is not possible to obtain the individual’s
acknowledgement, describe the good faith efforts made to obtain the
individual’s acknowledgement, and the reasons why the acknowledgement was not
obtained.
______________________________________________________________________
_________________________________________ Date:
__________________
_______________________________________
Signature of provider representative
_______________________________________
Title of provider representative