Daphne Fatter, Ph.D.
Licensed Psychologist #36337
2600 Eldorado Pkwy Ste 230 469-320-9668
McKinney, TX 75025 www.daphnefatterphd.com
TEXAS HIPAA NOTICE OF PRIVACY PRACTICES
Notice of Psychologists’ 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.
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 written authorization. “PHI” refers to information in your health record that could identify you. “Disclosure” applies to activities outside of my clinic, such as releasing, transferring, or providing access to information about you to other parties. “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
How I May Use And Disclose Health Information About You:
Other 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. 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 conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your record. It is not always the case that I have kept separate notes. These notes are given a greater degree of protection than PHI. You 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 the policy. I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.
List of Categories of Uses and Disclosures Permitted by HIPPA Without an Authorization:
Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
Your Rights Regarding your PHI:
Psychologist’s Duties: 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 our policies and procedures, I will provide you with a revised notice by making it available at my office and by posting it on my website.
Complaints: If 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 Daphne Fatter, Ph.D. at 469-320-9668. If you believe that your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to Daphne Fatter, Ph.D. You may also send a complaint to the Texas State Psychologist Board at 512-305-7709 or 1-800-821-3205 with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201; or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.
Effective Date, Restrictions and Changes to Privacy Policy: 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 either in person or on my website.
The effective date of this notice is August 1, 2015.
Licensed Psychologist #36337
2600 Eldorado Pkwy Ste 230 469-320-9668
McKinney, TX 75025 www.daphnefatterphd.com
TEXAS HIPAA NOTICE OF PRIVACY PRACTICES
Notice of Psychologists’ 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.
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 written authorization. “PHI” refers to information in your health record that could identify you. “Disclosure” applies to activities outside of my clinic, such as releasing, transferring, or providing access to information about you to other parties. “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
How I May Use And Disclose Health Information About You:
- For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with another health care provider, such as your family physician or other treatment team members.
- For Payment: I may use or disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
- For Health Care Operations: I may use or disclose, as needed, your PHI in order to support business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
- Required by Law. Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.
Other 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. 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 conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your record. It is not always the case that I have kept separate notes. These notes are given a greater degree of protection than PHI. You 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 the policy. I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.
List of Categories of Uses and Disclosures Permitted by HIPPA Without an Authorization:
- Child Abuse & Neglect: If I have reasonable cause to believe a child known to me in my professional capacity may be an abused child or a neglected child, I must report this belief to the appropriate authorities.
- Adult. Elder Abuse and Domestic Abuse: If I have reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, I must report this belief to the appropriate authorities.
- Health Oversight Activities: I may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.
- Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and I must not release such information without a court order. I can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization 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 must be informed in advance if this is the case.
- Emergencies, Serious Threat to Health, Safety or Public: If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
- Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.
- Law Enforcement and National Security: When the use and disclosure without your consent or authorization is allowed under other sections of Section 1.64.512 of the Privacy Rule and the confidentiality laws on Texas. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency, to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
Your Rights Regarding your PHI:
- Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am 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 me. Upon your request, I will send your bills to another address.)
- Right to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
- Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Restrict Disclosures Associated With Out of Pocket Payment: you have the right to restrict certain disclosures of PHI to health plans or insurance companies if you pay out-of-pocket in full for services.
- Breach Notification. If there is a breach of unsecured protected health information concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself
- Right to a Copy of this Notice: You have the right to a copy of this notice.
Psychologist’s Duties: 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 our policies and procedures, I will provide you with a revised notice by making it available at my office and by posting it on my website.
Complaints: If 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 Daphne Fatter, Ph.D. at 469-320-9668. If you believe that your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to Daphne Fatter, Ph.D. You may also send a complaint to the Texas State Psychologist Board at 512-305-7709 or 1-800-821-3205 with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201; or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.
Effective Date, Restrictions and Changes to Privacy Policy: 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 either in person or on my website.
The effective date of this notice is August 1, 2015.