HIPAA COLORADO NOTICE FORM

NOTICE OF PSYCHOTHERAPIST’S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL / PSYCHOTHERAPEUTIC 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
ABTC 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 you.
·      "Treatment, Payment and Health Care Operations"
– Treatment is when ABTC provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when ABTC consults with another health care provider, such as your family physician or another psychologist /psychotherapist.
– Payment is when ABTC obtains reimbursement for your healthcare. Examples of payment are when ABTC discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage (in order to maximize your insurance reimbursement directly to you).
– Health Care Operations are activities that relate to the performance and operation of ABTC’s 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 ABTC’s practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
·      "Disclosure" applies to activities outside of ABTC’s practice such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
ABTC 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 ABTC is asked for information for purposes outside of treatment, payment or health care operations, ABTC will obtain an authorization from you before releasing this information.
You may revoke any authorization at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) ABTC 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 with Neither Consent nor Authorization
ABTC may use or disclose PHI without your consent or authorization in the following circumstances:
·      Child Abuse – If ABTC has reasonable cause to believe that a child has been abused, ABTC must report that belief to the appropriate authority.
·      Adult and Domestic Abuse – If ABTC has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, ABTC must report that belief to the appropriate authority.
·      Health Oversight Activities – If ABTC is the subject of an inquiry by the Colorado Board of Licensed Professional Counselors, ABTC may be required to disclose protected health information regarding you in proceedings before the Board.
·      Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services ABTC provided you or the records thereof, such information is privileged under state law, and will not be released information without your written consent 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 ABTC determines, or pursuant to the standards of the supervising therapist’s profession should determine, that you present a serious danger of violence to yourself or another, that or another ABTC therapist may disclose information in order to provide protection against such danger for you or the intended victim.
·      Worker’s Compensation – ABTC 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 Psychotherapist’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, the ABTC therapist 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 ABTC therapist. On your request, ABTC will send correspondence to you to another address.)
·      Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in ABTC mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. The ABTC therapist may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your ABTC therapist 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. Your ABTC therapist may deny your request. On your request, the ABTC therapist 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, the ABTC therapist 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 ABTC upon request, even if you have agreed to receive the notice electronically.
Psychotherapist’s Duties:
·      ABTC is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
·      ABTC reserves the right to change the privacy policies and practices described in this notice. Unless ABTC notifies you of such changes, however, ABTC is required to abide by the terms currently in effect.
·      If ABTC revises its policies and procedures, these revisions will post in the waiting area and will be provided upon written request.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision ABTC makes about access to your records, or have other concerns about your privacy rights, you may contact ABTC at our office telephone number, which is 970-482-7771.
If you believe that your privacy rights have been violated and wish to file a complaint with ABTC, you may send your written complaint to Clinical Director at the ABTC office address, which is 1918 South Lemay, Ste. B, Fort Collins, Colorado 80525.
You may also send a written complaint to the Colorado Board of Examiners for Licensed Professional Counselors.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice is effective January 1, 2008.
ABTC reserves the right to change the terms of this notice, make restrictions or limitations, and to make the new notice provisions effective for all PHI that ABTC maintains. ABTC will provide you with a revised notice by posting the revisions in our waiting area. A written copy will be provided upon written request.

HIPAA COLORADO NOTICE FORM / ALPINE BEHAVIOR THERAPY CLINIC

The Health Insurance Portability and Accountability Act, or HIPAA, is a federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPAA requires that the Alpine Behavior Therapy Clinic provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The HIPAA regulations are compliant within the client consent for treatment forms you have been provided.  These forms, on file at ABTC are a part of your confidential record and are included as part of our mental health services agreement to your or your family members who are minors. Specific HIPAA regulations and their application to your personal mental health information are posted in greater detail for you at ABTC.  The law requires that ABTC obtain your signature acknowledging that you have been provided with this information. 

In accordance with HIPAA, ABTC keeps mental health information and records confidential and will only use them for client treatment, health care operations and billing purposes.

Treatment: Our staff psychotherapists and psychologist will use your mental health information to give you the best possible care.       

Health Care Operation:  Alpine Behavior Therapy Clinic will use this information to appropriate follow-up care, and client notification.

Billing purposes: Alpine Behavior Therapy Clinic will use your mental health information to supply the appropriate third party(s) with identifying information in order for you to maximize your insurance reimbursement for services provided to you at ABTC. 

DISCLOSURE OF INFORMATION WITH EXTENUATING CIRCUMSTANCES

1.   Mental health information will be given to family members in case of an emergency or under other circumstances with proper authorization and documentation.
2.   Mental health information may be given to other licensed psychotherapists, mental health professionals or medical professionals or institutions under emergency situations.
3.   Information may be given to proper authorities when neglect or abuse in alleged or suspected. 
4.   Information may be provided to courts or other agencies when a subpoena is given to this office.

ABTC is required to follow the privacy practices described in this notice, though we reserve the right to change our privacy practices and the terms of this notice at any time. If we do so, we will post a new notice in our waiting room area and on our professional website.
You may request a copy of the new notice from the Clinical Director at ABTC. 

I understand that if I have any questions I can speak to an Alpine Behavior Therapy Clinic Privacy Officer (Lisa Kurth, M.S. L.P.C, Clinical Director).