MAINE NOTICE FORM

Thank you to Angela McMahon, LCSW, for putting this together.

Notice of Health Psych Maine Policies and Practices to Protect the Privacy of Your Health Information

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.

• ''PHI'' refers to information in your health record that could identify you.
• ''Treatment, Payment, and Health Care Operations''
• Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist or clinician.
• Payment is when we obtain reimbursement for 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.
• Health Care Operations are activities that relate to the performance and operation of our 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 our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• ''Disclosure'' applies to activities outside of our office, 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

We 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 we are asked for information for purposes outside of treatment, payment, or health care 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 (1) We 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

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

• Child Abuse - If we know or have reasonable cause to suspect that a child has been abused or neglected, we must report the matter to the appropriate authorities as required by law.
• Adult and Domestic Abuse - If we suspect that an adult has been abused, neglected, or exploited and we have reasonable cause to suspect that the adult is incapacitated or dependent, we must report the matter to the appropriate authorities as required by law.
• Health Oversight Activities - We may disclose PHI to the Maine Board of Examiners of Psychologists, or one of its representatives, pursuant to standards or regulations for regulation, accreditation, licensure, or certification.
• Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or 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 or Safety - If, in our reasonable professional judgment, we believe that you pose a direct threat of imminent harm to the health or safety of any individual, including yourself, we may disclose PHI to the appropriate persons.
• Worker's Compensation - We may disclose PHI 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.

IV. Patient's Rights and Psychologist's/Clinician'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, we are 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 us. On your request, we 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. We must permit you to request access to inspect or to obtain a copy (or both) of your Clinical Record, unless we believe that such access would be detrimental to your health. If you are denied access to your Clinical Record, it is possible upon presentation of a written authorization signed by you that such notes or a ''narrative'' of the notes may be made available to your ''authorized representative.'' 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 an amendment of 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.
• Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI. On your request, we 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 us upon request, even if you have agreed to receive the notice electronically.

Psychologist's/Clinician's Duties:

• We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
• We reserve 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, we will provide you with a revised notice either in person or by mail.

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our privacy officer:

Jeri Wilson, Practice Manager
Health Psych Maine
2 Big Sky Lane
Waterville, Maine 04901
(207) 872-5800

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 April 14, 2003.

We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice either in person or by mail.