THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY. THANK YOU.

We are committed to maintaining the privacy of your protected health information (PHI), which includes information about you and the services you receive from us. This notice details how your PHI may be used and disclosed to third parties as well as your rights regarding your PHI.

1. 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 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 we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.

Payment is when we obtain reimbursement for your health care. Examples of payment are when we 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 our 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 case coordination.

Use applies only to activities within our office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Disclosure applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.

2. Uses and Disclosures Requiring Authorization

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

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

3. Uses and Disclosures with Neither Consent or Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances.

Child Abuse--When we have reasonable cause to believe that a child has been subjected to abuse or neglect, or if we observe a child being subjected to conditions which would reasonably result in abuse or neglect, we must report this to the proper law enforcement agency or to the Nebraska Department of Health and Human Services.

Adult and Domestic Abuse--When we have reasonable cause to believe that a vulnerable adult has been subjected to abuse, or if we observe such an adult being subjected to conditions which would reasonably result in abuse, we must report this to the appropriate law enforcement agency or the Nebraska Department of Health and Human Services.

Vulnerable adult means any person 18 years of age or older who has a substantial mental or functional impairment or for whom a guardian has been appointed under the Nebraska Probate Code.

Health Oversight Activities--For the purpose of any investigation, the Director of Health and Human Services or the Director of Regulation and Licensure (the board which licenses us to practice) may subpoena relevant records from us.

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 we will not release information with written authorization from you or your personal or legally-appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party, when the evaluation is court-ordered, or when you have placed your mental health at issue with a court (e.g. contested child custody). We will inform you in advance if this is the case.

Serious Threat to Health or Safety--If you communicate to us a serious threat of physical violence against a reasonably identifiable victim or victims, we must communicate such threat to the victim or victims and to a law enforcement agency.

Workers Compensation--If you file a worker's compensation claim, we must, on demand, make available records relevant to that claim to your employer, the insurance carrier, the worker's compensation court, and to you.

De-identified Information--We may use PHI that does not identify you and without your name cannot be used to identify you.

Business Associates--We may disclose PHI to a business associate if we have obtained satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists us in undertaking some essential function, such as a company that assists with submitting claims to insurance companies or other payers or a company that assists with collections of delinquent accounts.

4. 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, we are not required to agree to a restriction you request.

Right to Receive Confidential Communication 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 us. On your request, we 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. This may not include handwritten psychotherapy notes taken during sessions and later used to create the PHI in your actual healthcare record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request we 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. We may deny your request. On your request, we 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 for which you have neither provided consent nor authorization (as described in Section 3 of this Notice). On your request, we 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 us upon request, even if you have agreed to receive the notice electronically.

Psychologist's Duties

We are required by law to maintain the privacy of PHI and provide you with a notice of our legal duties and privacy practices with respect to PHI.

We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

If we revise our policies and procedures, we will advise you of this in person or by mail.

5. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, please contact our Privacy Officer, Kathy Lewis, about your concern.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request.

6. Effective Date, Restrictions and Changes to Privacy Policy