PRIVACY POLICIES

HIPAA NEW YORK NOTICE FORM
Notice of 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

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

• PHI: Protected health information, which includes demographic and health information that can identify you.
• Treatment, Payment, and Health Care Operations:
  • Treatment: Providing, coordinating, or managing your health care and services, such as consulting with another healthcare provider.
  • Payment: Obtaining reimbursement for healthcare services, such as disclosing PHI to insurers.
  • Health Care Operations: Business-related activities like quality assessments, audits, and case management.
• Use: Activities within my practice, such as sharing and analyzing information.
• Disclosure: Activities outside my practice, such as providing access to PHI to other entities.

II. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes beyond treatment, payment, and operations only with your written authorization. You may revoke this authorization in writing at any time, except where reliance on prior authorization is necessary (e.g., insurance claims).

III. Uses and Disclosures Without Consent or Authorization

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

• Child Abuse: If we suspect child abuse or maltreatment, we must report it to the authorities.
• Health Oversight: If an inquiry or complaint is made to the New York State Office of Professions, we must provide relevant mental health records.
• Judicial or Administrative Proceedings: PHI may be disclosed if a court orders it or if an evaluation is court-mandated.
• Serious Threat to Health or Safety: Confidential information may be disclosed to prevent harm to you or others.
• Worker’s Compensation: If you file a claim, we must provide relevant treatment records to the Worker’s Compensation Board.

IV. Patient Rights and Therapist Responsibilities

Patient Rights:

• Right to Request Restrictions: You may request restrictions on certain PHI uses, but we are not obligated to agree.
• Right to Confidential Communications: You may request alternative methods or locations for receiving communications.
• Right to Inspect and Copy: You may access and obtain a copy of your PHI records.
• Right to Amend: You may request amendments to your PHI, which we may deny under certain conditions.
• Right to an Accounting of Disclosures: You may request a list of PHI disclosures not covered by consent.
• Right to a Paper Copy: You may request a paper copy of this notice at any time.

Therapist Responsibilities:

• We are required by law to maintain the privacy of your PHI.
• We may revise these policies and will provide you with updated versions when applicable.
• If we revise these policies, we will provide an updated notice at your request.

V. Questions and Complaints

If you believe your privacy rights have been violated or disagree with a decision about your records, contact:

• Racheli Miller, Ph.D., Licensed Psychologist (Director) at (347) 391-0086.
• If you do not feel comfortable doing so, contact the New York State Licensing Board at 1-800-442-8106 or email conduct@mail.nysed.gov.
• You may also file a complaint with the U.S. Department of Health and Human Services at www.hhs.gov/ocr/hipaa.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

• This notice took effect on September 9, 2009.
• We reserve the right to modify these policies and will provide updated copies when necessary.
• If you are no longer in therapy, you may request a revised notice in writing.