Elaine Ducharme Ph.D. ABPP
Board Certified in Clinical Psychology
Parker Terrace Extension
Notice of Psychologist’s 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
I may use or disclose your protected health
information (PHI), for treatment, payment, and health care operations purposes with your consent.
To help clarify these terms, here are some definitions:
· “PHI” refers to information in your health record that could identify
“Treatment, Payment and
Health Care Operations”
– Treatment is when I provide, coordinate or manage your health care and other
services related to your health care. An example of treatment would be when I consult with another health care provider,
such as your family physician or another psychologist.
– Payment is when I obtain reimbursement for your healthcare. Examples
of payment are when I disclose 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
my practice. Examples of health care operations are quality assessment and improvement activities, business-related
matters such as audits and administrative services, and case management and care coordination.
· “Use” applies only to activities within my [office,
clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies
applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing
access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes
outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization”
is written permission above and beyond the general consent that permits only specific disclosures. In those instances
when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization
from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy
Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group,
joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are
given a greater degree of protection than PHI.
may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing.
You may not revoke an authorization to the extent that (1) I have 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
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in
the following circumstances:
Child Abuse – If I, in the ordinary course of my profession, have reasonable
cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had nonaccidental
physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is
placed at imminent risk of serious harm, then I must report this suspicion or belief to the appropriate authority.
Adult and Domestic Abuse – If I know or in good faith suspect that an elderly individual
or an individual, who is disabled or incompetent, has been abused, I may disclose the appropriate information as permitted
Health Oversight Activities – If the Connecticut Board of Examiners of Psychologists is
investigating my practice, the board may subpoena records relevant to such investigation.
· Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis
and treatment and the records thereof, such information is privileged under state law, and I will not release information
without the written authorization of you or your legally appointed 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. You will be informed
in advance if this is the case.
Serious Threat to Health or
Safety – If I believe in good faith that there
is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals,
I may disclose the appropriate information as permitted law.
· Worker’s Compensation –
I 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
Right to Request Restrictions
– You have the right to request restrictions
on certain uses and disclosures of protected health information. You have the right to restrict certain disclosures
of Protected Health Information (PHI) to a health plan if you pay out-of-pocket in full for the healthcare service.
Breach of unsecured PHI – You have the right to be notified if there is a breach of
your unsecured PHI.
Right for signed authorization- I must have a signed authorization before I can release your PHI
for any uses and disclosures not described in the Privacy Notice.
· 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 me. On your request, I 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 my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.
I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On
your request, I 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. I may deny your request. On your request, I 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,
I 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
I am required by law to maintain
the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
· I reserve the right to change the privacy policies and practices described
in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
· If I revise my policies and procedures, I will provide you with the
V. Questions and Complaints
you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns
about your privacy rights, you may contact me at 17 Parker Terrace Ext., Glastonbury, CT. 06033. My phone number is: 860-633-8962.
You may also send a written complaint to the Secretary of the U.S.
Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not
retaliate against you for exercising your right to file a complaint.
I reserve the right to change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain. I will provide you with a revised notice.