This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
EFFECTIVE DATE: 1/1/2024
Health Psych Maine (“HPM”) is committed to protecting your privacy. This Notice of Privacy Practices describes how HPM may use and disclose your Protected Health Information (PHI) under applicable federal and state law to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. This Notice also describes your rights to access and control your PHI.
“Protected health information” or “PHI” is individually identifiable health information about you, including demographic information collected from you, that is created or received by HPM and that relates to (i) your past, present, or future physical or mental health or condition, (ii) the provision of health care to you, or (iii) the past, present or future payment of your health care. PHI also includes any health information and records provided to HPM by other health care providers and facilities who have provided care to you or are involved in your care.
- HPM is required by law to maintain the privacy of your PHI, to provide you with this Notice of its legal duties and privacy practice with respect to your PHI, and to notify affected individuals following a breach of unsecured PHI.
- HPM is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, HPM will abide by the more stringent law.
- HPM reserves the right to amend this Notice. All changes are applicable to PHI collected and maintained by HPM. Should HPM make changes to this Notice, HPM will provide you with a revised notice or you may obtain a revised Notice by requesting a copy from HPM at the address listed above, or by viewing a copy on the website hpmaine.com.
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to HPM at the address noted above.
- You have the right to access, inspect and copy your PHI. This means you may inspect at reasonable times and obtain a copy of your clinical records and billing records within 30 days of receipt of your written request. If we need extra time, we may extend the time once for an additional 30 days and we will provide you written notice of the extension. You have the right to receive your health information in the form and format of your choosing, if such information can be readily produced in such form and format, or in a readable hardcopy form, or in another format agreed to between you and HPM. If HPM maintains your PHI in an electronic health record, you have the right to obtain a copy of your health information in an electronic format and to direct HPM to transmit an electronic copy of your PHI directly to another clearly specified entity or person of your choice. You may be charged reasonable costs (including labor and supplies) associated with providing copies of your records, or of preparing any summaries that you request. In certain limited circumstances, you may be denied access to your health information and records, such as, but not limited to, if HPM believes that the disclosure will endanger your life or another person's life. However, you may request that a decision denying you access to your PHI and records be reviewed. Please contact HPM’s Practice Manager if you have questions about your right to access your PHI.
- You have the right to request a restriction on certain uses and disclosures of your PHI. For example, you may request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. If you request that HPM not disclose your PHI to a third-party payor health plan for purposes of carrying out payment or health care operations, and you have paid HPM in full out of pocket for services provided to you, HPM is required to honor your requested restriction. Otherwise, HPM is not required to agree to a requested restriction and has sole discretion to decide whether to honor a requested restriction on a case-by-case basis. If HPM agrees to a requested restriction, HPM will not use or disclose your PHI in violation of the agreed upon restriction, unless the use or disclosure is needed to provide emergency treatment. Your request for a restriction must state the specific restriction requested and to whom you want the restriction to apply. Disclosures of PHI authorized by you or permitted or required by law as described in this Notice, may include disclosures of PHI HPM has received from other health care providers and facilities, unless you request, and HPM agrees to, a requested restriction on the disclosure of such information.
- You have the right to request to receive confidential communications of PHI from us by alternative means or at an alternative location. HPM will accommodate reasonable requests. HPM may place conditions on such accommodations, for example, by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. HPM will not request an explanation from you as to the basis for the request. Please make such requests in writing to HPM’s Practice Manager.
- You have the right to submit amendments, corrections and clarifications to your PHI. You may request amendments, corrections and clarifications to PHI contained in your medical records. Your request must be in writing and you must provide a reason supporting your request. If you are requesting a change to the PHI in your treatment record, we will place your requested amendment, correction or clarification in your record. HPM may add a response to your record and will provide to you a copy of its response. If you are requesting a change in other records (that are neither medical nor billing records), HPM may deny your request. If your request is denied, it will notify you in writing and provide its reasons for the denial. You have the right to file a statement of disagreement with HPM’s Practice Manager and HPM may prepare a response to your statement. HPM will provide you with a copy of its response. Please contact HPM’s Practice Manager if you have any questions about modifying your PHI.
- You have the right to receive an accounting of certain disclosures. You have the right to receive an accounting of certain disclosures of your PHI made by HPM in the six years prior to the date of your request. The accounting will not include disclosures made directly to you, disclosures made to others pursuant to your written authorization, disclosures made to carry out treatment, payment, and health care operations for which your written authorization was not required, incidental uses and disclosures, and other uses and disclosures for which an accounting is not required to be provided by law. To request an accounting of disclosures of your PHI, contact HPM’s Practice Manager.
- Important Notice to Minors Regarding Minor’s Privacy Rights. If you are a minor authorized by law to consent to health care services on your own behalf and you in fact consent to such services on your own behalf, HPM is required to protect the privacy of your PHI with respect to health care services you have consented to on your own behalf in the same way that HPM protects the privacy of an adult’s PHI, unless a special exception applies under the law. For example, HPM is authorized by law to notify your parent or guardian if, in the judgment of your HPM provider, failure to inform your parent or guardian would seriously jeopardize your health or would seriously limit the ability of your HPM provider to provide treatment to you. Additionally, if you want HPM to bill your parent’s or parents’ health insurance plan for services provided to you, your parents will receive from their insurance company an Explanation of Benefits regarding the services provided to you by HPM and, as a result, the fact that you received services from HPM will not be confidential from your parents. However, if you do not want your parents to know that you are receiving services from HPM, you must notify HPM of that fact at the time services are provided to you so that arrangements can be made for payment of such services privately or out-of-pocket, or to determine your eligibility for free or discounted care. While HPM believes that privacy in psychotherapy is very important, particularly with minors, parental involvement is also usually important for successful treatment, particularly with younger children. Therefore, HPM will work with you to develop an agreement about what information may be shared with your parents.
- You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically.
- You have the Right to file a complaint. If you feel your privacy rights have been violated, you can file a complaint with HPM or the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with HPM by contacting HPM’s Practice Manager at the contract information provided below. HPM will not retaliate against you for filing a complaint.
Authorized Uses and Disclosures of Your Protected Health Information
1. Routine Uses and Disclosures of PHI
HPM is permitted to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. HPM typically uses or shares your health information in the following ways:
- For Treatment, Care Management and Coordination of Care Purposes
HPM may use your PHI internally for treatment-related purposes, such as to provide counseling, therapy, treatment and health care services to you, and to coordinate and manage the health care treatment and services it provides to you. This includes consultation with clinical supervisors or other team members regarding your care. In an emergency, HPM may disclose your PHI to other health care practitioners, facilities or consultants outside of HPM office for diagnosis, treatment or care, or to complete the responsibilities of such persons or entities that provided diagnosis, treatment or care to you. However, if HPM discloses your PHI to a health care practitioner or health care facility outside of its office, or to a payor or person engaged in payment for health care, for purposes of care management or coordination of care, HPM will make a reasonable effort to notify you of such disclosure.
- For Health Care Operations Purposes
HPM may use and share PHI for certain health care operations purposes, such as quality review and improvement activities and risk management activities.
- For Payment Purposes
HPM may use and share your PHI internally for payment related purposes, including to obtain payment from health plans or other entities for services rendered to you. Additionally, HPM may disclosure your PHI to health insurance companies or other third-party payors for payment purposes, including to determine your eligibility for coverage or benefits or to obtain reimbursement for service provided to you, unless, you pay in full out of pocket for services provided to your and request in writing that your PHI not be disclosed to third-party payors. If it becomes necessary for HPM to pursue a collection against you for your failure to pay for services provided to you, HPM may disclose your PHI to its legal counsel and to outside collection agencies acting as business associates of HPM for purposes of such collection activities.
2. Uses and Disclosures of PHI That May Be Made Without Your Authorization
HPM may use or disclose your PHI without your authorization in the following additional circumstances:
- Public Health Activities: HPM may use and disclosure your PHI to public health authorities for public health activities.
- Health Oversight Activities: HPM may use and disclose your PHI to a health oversight agency for activities authorized by law such as compliance with health oversight audits, investigations, licensure surveys and inspections, and complaint investigations. Oversight agencies authorized to receive your PHI include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs, including Maine health care professional licensing boards.
- To Avert Threats of Harm or Safety: To prevent or lessen a direct threat of serious and imminent harm to health or safety.
- Victims of Abuse, Neglect, Domestic Violence, or Sexual Assault Reporting: If HPM reasonably believes that you are a victim of abuse, neglect, domestic violence or sexual assault, HPM may, in certain circumstances, disclose your PHI to a federal, state or local government authority, including a social service or protective services agency, authorized by law to receive such reports, e.g., if HPM believes the disclosure is necessary to prevent serious harm to you or other potential victims. To report abuse, neglect, or domestic violence.
- Child and Dependent or Incapacitated Adult Abuse, Neglect, and Exploitation Reporting: HPM may disclose your PHI to government authorities, such as Child Protective Services or Adult Protective Services, that are authorized by law to receive reports of actual or suspected cases of abuse, neglect, or exploitation of children and incapacitated or dependent adults.
- Business Associates: HPM may disclose your PHI to business associate contractors performing services for or on behalf of HPM when such contractors (i) require your PHI to perform such contracted services for HPM, and (ii) have agreed in writing to appropriately protect your PHI.
- Judicial and Administrative Proceedings: HPM may disclosure your PHI in judicial or administrative proceedings when required or authorized by law, for example, to respond to a court order, or pursuant to a subpoena served by a governmental entity authorized by law to have access to your PHI.
- Law Enforcement Purposes: HPM may disclose your PHI, so long as applicable legal requirements are met, for certain law enforcement purposes such as to report crimes committed on HPM’s premises, or crimes committed against HPM’s personnel.
- Specialized Government Functions: HPM may disclose your PHI for the following specialized government functions when such disclosures are authorized or required by applicable law:
- Armed Forces and Foreign Military Personnel: To persons who are members of the Armed Forces and of foreign military personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of a military mission.
- National Security and Intelligence Activities: To authorized federal officials for the conduct of lawful intelligence, counterintelligence, and other national security activities authorized by the National Security Act and related Executive Orders.
- Protective Services for the President and Others: To authorized federal officials for the provision of protective services to the President or other persons, or for the conduct of investigations, authorized under applicable federal law.
- Correctional Institutions and Law Enforcement Custodians: To a correctional institution or a law enforcement official having lawful custody of an inmate or other individual, PHI about the inmate or other person when necessary (i) to provide health care to the inmate or person in custody, (ii) for the health and safety of the inmate or person in custody, (iii) for the health and safety of correctional personnel, (iv) for the health and safety of persons responsible for transporting the inmate or person in custody, (v) for law enforcement on correctional facility premises, and (vi) for administering and maintaining the safety, security and good order of the correctional institution.
- Workers' Compensation: HPM may disclosure your PHI when authorized by, and to comply with, workers' compensation laws or other similar programs that provide benefits for work-related injuries or illness without regard to fault.
- To comply with other requests
- Coroners and Funeral Directors: To perform their legally authorized duties.
- Organ Donation: For organ donation or transplantation.
- Research: HPM may disclosure your PHI for research purposes that has (i) been approved by an institutional review board or a privacy board; and (ii) no identifying information about you is disclosed in any report arising from or published in connection with the research.
- Personal or Authorized Representatives: HPM may disclose your PHI to a personal or authorized representative, such as your health care power of attorney agent, guardian, or health care surrogate—or, in the case of minor who has not consented to health care treatment in accordance with Maine law, the minor’s parent, legal guardian or guardian ad litem—who is authorized by law to make health care decisions on your behalf when you lack the capacity to make your own health care decisions.
- Persons Involved in Your Care and for Notification Purposes: HPM may disclose your PHI to family members, relatives, or close personal friends involved in your care, involved in securing payment for your care, or for notification purposes, unless you or your personal representative notifies HPM that you object to and wish to prohibit or restrict such disclosures.
- Disaster Relief: HPM may use and disclose your PHI to public or private entities authorized by law to assist in disaster relief efforts for certain notification purposes, provided you have been given the opportunity to agree or to object to such uses and disclosures.
- When otherwise Required or Authorized by Law: HPM may use and disclose your PHI for other purposes when required or authorized by applicable state and federal law. It may also use and disclose your PHI if it is in your best interest because you are unable to state your preference.
3. Uses and Disclosures of PHI Based Upon Your Written Authorization
For other types of uses and disclosures not described in this Notice, the Practice will obtain your written authorization to use or disclose your PHI. For example, the following uses and disclosures require HPM to obtain your written authorization:
- Psychotherapy Notes: In the event that HPM maintains psychotherapy notes about you that are kept separate from the rest of your Practice medical record, HPM will obtain your written authorization to use or disclose such psychotherapy notes unless an exception to the authorization requirement applies under applicable law.
- Marketing: HPM will obtain your written authorization for any use or disclosure of your PHI to sell or market products or services, except in limited circumstances where marketing is permitted by applicable law (for example, in face-to-face marketing communications with you).
- Sale of PHI: HPM will obtain your written authorization for any disclosure of your PHI that involves a sale of your PHI, unless an exception applies under applicable law.
- Photographs and Video recordings: HPM will not photograph or videorecord you, or use or disclose any photographs and video recordings of you, for purposes unrelated to treatment, or for marketing or public relations purposes, without your written authorization, unless the creation, use or disclosure of such photographs or video recordings is authorized by law (e.g., for HPM facility security surveillance purposes).
Right to Revoke Authorization: You may revoke your authorization, at any time to the extent that HPM or others have not already relied upon your authorization, by contacting HPM in writing at the address above.
Special Protections for Certain Types of Especially Sensitive Protected Health Information
Confidentiality of Mental Health Information: If HPM maintains information about you derived from mental health services provided to you by a Practice psychiatrist, psychologist, clinical nurse specialist, social worker or counseling professional, HPM will not disclose such mental health information to another health practitioner or facility outside of HPM or its organizational affiliates for a diagnostic, treatment or continuity of care purpose, without your written authorization, unless such disclosure is necessary in an emergency or is otherwise authorized or required by law.
Confidentiality of HIV Information: If HPM maintains any information regarding your HIV status (such as HIV test results or medical records containing HIV information), such information is afforded heightened protection under Maine law and HPM will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by Maine’s HIV confidentiality laws.
Confidentiality of Substance Use Disorder Program Information: If HPM acquires from a substance use disorder program or is a lawful holder of, any records or information about you that is subject to the heightened federal confidentiality protections afforded to certain substance use disorder program records under 42 C.F.R. Part 2, HPM will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by 42 C.F.R. Part 2. If HPM creates, acquires or maintains any substance use disorder information about you that is not from a Part 2 substance use disorder program, HPM will protect the confidentiality of such information, and use and disclose such information, in the same way HPM protects, uses and discloses your other PHI.
Contact HPM for More Information
If you have any questions about this Notice, or would like more information about HPM’s privacy practices, or would like to file a complaint with HPM, please contact HPM’s Practice Manager at:
Attn: Eliza Meyer, Practice Manager
Health Psych Maine
2 Big Sky Ln, Waterville, ME 04901