Notice of ACP Consultants' (ACP) 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.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

  ACP may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

·        "PHI” refers to information in your health record that could identify you.

·        "Treatment, Payment, and Health Care Operations"

- Treatment is when ACP provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when ACP consults with another health care provider, such as your family physician or another psychologist.

- Payment is when ACP obtains reimbursement for your healthcare. Examples of payment are when ACP discloses 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 the practice of ACP. Examples of matters such as audits and administrative services, and case management health care operations are quality assessment and improvement activities, business-related and care coordination.

·         "Use" applies only to activities within ACP [office, clinic, practice group, etc.] such as

sharing, employing, applying, utilizing, examining, and analyzing information that

identifies you.

·        '`Disclosure" applies to activities outside of ACP [office, clinic, practice group, etc.], 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

ACP 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 ACP is asked for information for purposes outside of treatment, payment, or health care operations, ACP will obtain an authorization from you before releasing this information.

ACP will also need to obtain an authorization before releasing your Psychotherapy Notes. "Psychotherapy Notes" are notes your ACP provider may have made about conversations during a private, group, joint, or family counseling session, which your ACP provider has kept separate from the rest of your record. These notes are given a greater degree of' protection than PHI.

You may revoke all such authorizations (or PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) ACP has 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

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

       ·          Child Abuse -If your ACP provider has reasonable cause to believe a child known to me in my professional capacity may be an abused child or a neglected child, he/she must report this belief to the appropriate authorities.

·       Adult and Domestic Abuse -If your ACP provider has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, he/she must report this belief to the appropriate authorities.

·     Health Oversight Activities - ACP may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.

·        Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and ACP must not release such information without a court order. ACP can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.

·       Serious Threat to Health or Safety -If you communicate to your ACP provider a specific threat of imminent harm against another individual or if your ACP provider believes that there is clear, imminent risk of physical or mental injury being inflicted against another individual, your ACP provider may make disclosures that he/she believes are necessary to protect that individual from harm. If your ACP provider believes that you present an imminent, serious risk of physical or mental injury or death to yourself; your ACP provider may make disclosures he/she considers necessary to protect you from harm.

      ·          Worker's Compensation - ACP 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.

IV. Patient's Rights and Psychologist'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, ACP 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 an ACP provider. On your request, ACP 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 ACP's mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record and Psychotherapy Notes. On your request, your ACP provider will discuss with you the details of the request for access 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. ACP may deny your request. On your request, your ACP provider 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, your ACP provider 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 me upon request, even if you have agreed to receive the notice electronically.