Center For Individual & Family Therapy A Christian Counseling Center Family Forms (Page 3 of 6) in pdf

NOTICE OF POLICIES AND PRACTICES TO PROTECT

THE PRIVACY OF YOUR HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION

ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

GET ACCESS TO THIS INFORMATION AS PER HIPAA

REQUIREMENTS. PLEASE REVIEW IT CAREFULLY.

I. Disclosures for Treatment, Payment and Health Care Operations

A CIFT therapist may use or disclose your protected health information (PHI), for certain treatment,

payment, and health care operations purposes without your authorization. In certain circumstances, he or

she can only do so when the person or business requesting your PHI provides a written request that

includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms,

here are some definitions:

•

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

•

“Treatment” is when a therapist or another healthcare provider diagnoses or treats you. An example

of treatment would be when a therapist consults with another health care provider, such as your

family physician or another psychologist, regarding your treatment.

•

“Payment” is when a therapist obtains reimbursement for your healthcare.

•

“Use” applies only to activities within CIFT such as sharing, employing, applying, utilizing, examining,

and analyzing information that identifies you.

•

“Disclosure” applies to activities outside of CIFT such as releasing, transferring, or providing access

to information about you to other parties.

•

“Authorization” means written permission for specific uses or disclosures.

II. Uses and Disclosures Requiring Authorization

A therapist 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 we are asked for information for

purposes outside of treatment and payment operations, your therapist will obtain an authorization from you

before releasing this information. You may revoke or modify all such authorizations (of PHI or

psychotherapy notes) at any time; however, the revocation or modification is not effective until we receive

it.

III. Uses and Disclosures with Neither Consent nor Authorization

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

•

Child Abuse: Whenever a therapist, in his or her professional capacity, has knowledge of or observe a

child he or she knows or reasonably suspects has been the victim of child abuse or neglect, he or she

must immediately report such to a police department, sheriff’s department, county probation

department, or county welfare department. Also, if a therapist has knowledge of or reasonably suspects

that mental suffering has been inflicted upon a child or that his or her emotional well-being is

endangered in any other way, the therapist may report such to the above agencies.

•

Adult and Domestic Abuse: If a therapist, in his or her 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; if a therapist is told by an elder or

dependent adult that he or she has experienced these; or if a therapist reasonably suspects such, the

therapist must report the known or suspected abuse immediately to the local ombudsman or the local

law enforcement agency.

A therapist is not required to report such an incident if the therapist has been told by an elder or

dependent adult that he or she has experienced behavior constituting physical abuse, abandonment,

abduction, isolation, financial abuse or neglect and the therapist is not aware of any independent

evidence that corroborates the statement that the abuse has occurred; (a) the elder or dependent adult

has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservator

ship because of a mental illness or dementia; and (b) in the exercise of clinical judgment, the therapist

reasonably believes that the abuse did not occur.

•

Health Oversight: If a complaint is filed against a therapist with the California Board of Psychology or

the California Board of Behavioral Science, the Board has the authority to subpoena confidential mental

health information from the therapist relevant to that complaint.

•

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is

made about the professional services that I have provided you, I must not release your information

without (a) your written authorization or the authorization of your attorney or personal representative;

(b) a court order; or (c) a subpoena duces tecum (a subpoena to produce records) where the party

seeking your records provides me with a showing that you or your attorney have been served with a

Center For Individual & Family Therapy A Christian Counseling Center Family Forms Page 3

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