Notice of Privacy Practices
Your privacy is protected by the Health Insurance Portability and Accountability Act (HIPAA)
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.
SUMMARY
This Notice describes how your protected health information (PHI) is protected, and how Clementine Counseling PLLC may use and disclose this information. PHI includes personally identifiable information that relates to your past, present, or future health, treatment, or payment for health care services. Clementine Counseling PLLC professional staff are required to comply with this privacy policy, and share this information only when there is an appropriate reason to do so, such as to confer with other health care providers or to comply with emergency protocols.
Under the Health Insurance Portability and Accountability Act (HIPAA), you are afforded privacy rights regarding the use and disclosure of your health information. These include:
a right to be informed of the potential uses and disclosures of your protected health information, and to limit those uses and disclosures of this protected health information;
a right to receive this written notice that explains how we may use and disclose your protected health information, your rights under HIPAA’s privacy rule, Clementine Counseling PLLC’s responsibilities as a covered entity under HIPAA;
a right to a paper copy of this notice, or to have your legally designated representative receive a copy of this notice; you are asked to acknowledge receipt of this notice;
a right to amend your record, to restrict what information from your record is disclosed to others, and to receive an accounting of disclosures of this information that were made without your authorization, other than for treatment, payment or health care operations;
a right to have your complaints about our policies and procedures recorded in these records.
As a health care provider, Clementine Counseling PLLC is making a good faith effort to see that you or your representative have received and acknowledged this notice of privacy practices. If you are seen for emergency treatment, you will receive this notice as soon as practically possible afterward.
I. DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Clementine Counseling PLLC may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. To help clarify these terms, here are some definitions:
PHI refers to information in your health record that could identify you.
Treatment is when Clementine Counseling PLLC or another healthcare provider diagnoses or treats you. An example of treatment would be when Clementine Counseling PLLC consults with another health care provider, such as your family physician or another psychologist.
Payment is when Clementine Counseling PLLC obtains reimbursement for your healthcare. Examples of payment are when Clementine Counseling PLLC charges a card on file to pay a session fee.
Health Care Operations is when Clementine Counseling PLLC discloses your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
Use applies only to activities within Clementine Counseling PLLC’s practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of Clementine Counseling PLLC’s practice, such as releasing, transferring, or providing access to information about you to other parties.
Authorization means written permission for specific uses or disclosures. All authorizations to disclose must be on a specific, legally required form.
II. USES AND DISCLOSURES REQUIRING AUTHORIZATION
Clementine Counseling PLLC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when Clementine Counseling PLLC is asked for information for purposes outside of treatment and payment operations, Clementine Counseling PLLC will obtain an authorization from you before releasing this information.
You may revoke or modify all such authorizations of PHI at any time, provided each revocation is in writing; however, the revocation or modification is not effective until Clementine Counseling PLLC receives it. You may not revoke an authorization to the extent that (1) Clementine Counseling PLLC has relied on that information; 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
Clementine Counseling PLLC may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: Whenever Clementine Counseling PLLC, in its professional capacity, has knowledge of or observes a child Clementine Counseling PLLC knows or reasonably suspects, has been the victim of child abuse or neglect, Clementine Counseling PLLC must immediately report such to a police department or sheriff’s department, county probation department, or county or state welfare department.
Adult and Domestic Abuse: If Clementine Counseling PLLC, in its professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if Clementine Counseling PLLC is told by an elder or dependent adult that he or she has experienced these, or if Clementine Counseling PLLC reasonably suspects such, she must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency.
Health Oversight: If a complaint is filed against Clementine Counseling PLLC with the State Board that licenses its profession, the Board has the authority to subpoena confidential mental health information from Clementine Counseling PLLC relevant to that complaint.
Serious Threat to Health or Safety: If you communicate to Clementine Counseling PLLC a serious threat of physical violence against an identifiable victim, Clementine Counseling PLLC must make reasonable efforts to prevent harm, which may include communicating that information to the potential victim, and the police. If Clementine Counseling PLLC has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, Clementine Counseling PLLC may release relevant information as necessary to prevent the threatened danger.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that Clementine Counseling PLLC has provided you, Clementine Counseling PLLC must not release your information without your written authorization or the authorization of your attorney or personal 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. Clementine Counseling PLLC will inform you in advance if this is the case.
IV. PATIENT’S RIGHTS AND PROVIDER’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 about you. However, Clementine Counseling PLLC is 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 Clementine Counseling PLLC and may request that she not telephone your residence.
Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in Clementine Counseling PLLC’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Clementine Counseling PLLC may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, Clementine Counseling PLLC 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. Clementine Counseling PLLC may deny your request. On your request, Clementine Counseling PLLC 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 for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, Clementine Counseling PLLC 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 Clementine Counseling PLLC upon request, even if you have agreed to receive the notice electronically.
Duties of Provider:
Clementine Counseling PLLC 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.
Clementine Counseling PLLC reserves the right to change the privacy policies and practices described in this notice. Unless Clementine Counseling PLLC notifies you of such changes, however, they are required to abide by the terms currently in effect.
If Clementine Counseling PLLC revises its policies and procedures, Clementine Counseling PLLC will provide you with a written copy of the revised policies and procedures at the earliest possible opportunity following this revision, in person or by mail.
V. INFORMED CONSENT FOR TELEHEALTH SERVICES
Definition of Telehealth: Telehealth involves the use of electronic communications to enable Clementine Counseling PLLC mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, treatment, referral to resources, education, and the documentation of clinical information.
I understand that I have the following rights with respect to telehealth:
The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.
In choosing to participate in telehealth, I am agreeing to participate using video conferencing technology.
I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
I understand that my express consent is required to forward my personally identifiable information to a third party.
I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.
By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.
By agreeing to telehealth services, the therapist and participant are agreeing to participate in a secure and confidential setting. In the event that a client is unable to sustain a confidential environment for a telehealth session, the therapist may choose to remind the client of this requirement and will cease the session if confidentiality is not properly assured. A session will be rescheduled for another date with parameters for confidentiality begin re-explained.
VI. COMPLAINTS
If you are concerned that Clementine Counseling PLLC has violated your privacy rights, or you disagree with a decision Clementine Counseling PLLC made about access to your records, you may contact the Compliance Officer for further information.
For complaints, contact Clementine Counseling PLLC at (512) 710-5828, or at josephinebibbycounseling@gmail.com
You may also send a written complaint to the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619- 0257. Clementine Counseling PLLC will not retaliate against you for filing a complaint.
VII. RESTRICTIONS, AND CHANGES TO PRIVACY POLICY
Clementine Counseling PLLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that Clementine Counseling PLLC maintains. Clementine Counseling PLLC will provide you with a revised notice by mail, at the earliest opportunity following the revision.
Patient Consent: I have read and understand the information provided above regarding HIPAA and privacy practices. I have read this document carefully and understand the risks and benefits related to the use of privacy practices. I hereby give my informed consent to participate in the mental health treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.
