Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Privacy is a very important concern for all those who come to this office. It is also complicated, because of the many federal and state laws and my professional ethics. Because the rules are so complicated, some parts of this notice are very detailed, and you probably will have to read them several times to understand them. If you have any questions, I, as my own compliance officer will be happy to help you understand my procedures and your rights.
A. Introduction to my practice
B. Contents of this notice of privacy practices
A. Introduction: To my clients
B. What I mean by your medical information
C. Privacy and the laws about privacy
D. How your protected health information (PHI) can be used and shared
1. Uses and disclosures with your consent
a. The basic uses and disclosures: For treatment, payment, and health care operations
b. Other uses and disclosures in health care
2. Uses and disclosures that require your consent and authorization
3. Uses and disclosures that don’t require your consent or authorization
a. When required by law
b. For law enforcement purposes
c. For public health activities
d. For matters relating to deceased persons
e. For specific government functions
f. To prevent a serious threat to health or safety
4. Uses and disclosures where you have an opportunity to object
5. An accounting of disclosures I have made
E. Your rights about your protected health information
F. If you have questions or problems
Introduction to My Practice
Philosophy of Care: I am a clinical psychologist with training in psychodynamic and interpersonal psychotherapy, and clinical neuropsychology. I am also a teacher, and believe that knowledge is often very helpful when someone is struggling with life challenges. My work with patients pays heed to all of these disciplines—I work to help people understand the impact of the past on the present, to help them learn that sometimes they act on the basis of things that are not fully conscious, and to educate them on the structure and function of the brain, and the impact the brain has on the mind, and the mind has on the brain. In addition to the above, I believe strongly in the tenets of positive psychology, and the important role our chosen point of view has on every aspect of our lives.
You will find that my treatment is strength-based and focused on finding solutions to challenges, and that an overarching goal is to help you develop a coherent narrative about yourself, your life and your goals.
Background and Training: I graduated from CSPP Berkeley, where I was trained in the dynamic therapeutic traditions. I did a postdoctoral fellowship in clinical neuropsychology at San Francisco General Hospital. After finishing this two-year training, I remained at SFGH as an attending psychologist and joined the faculty in the School of Medicine at the University of California at San Francisco, where I trained medical students and psychiatry residents in the art and science of patient care. During my years at UCSF I maintained a faculty practice, working with individuals in psychotherapy.
I am now a professor in the undergraduate Psychology Department at Lewis and Clark College. Teaching there has helped me maintain a connection to young adults, and deepened my belief that understanding how our brains and minds work together can jump-start the process of change.
Treatment Options and Medical Necessity: I work with teenaged and adult individuals in psychotherapy. I do not see couples or families. I am not a physician, and thus do not provide medication services. If couples work, family therapy or medication management is needed, I will work to assist you in finding appropriate referrals, and will work in concert with those providers.
I do not take medical insurance. I will be glad to provide you with a bill to submit to your insurance company, but the reimbursement for my services is something you will undertake with your insurance plan directly. It is your responsibility to understand your coverage and negotiate coverage with your insurance plan. I have opted out of Medicare, and because of this, Medicare recipients cannot submit my superbills to their insurance for reimbursement.
Treatment Process: Services with me always begin with an assessment. We will discuss your current situation, your history, and the goals you have for treatment. After this discussion I will make a recommendation for services. If that plan includes my services and together we feel that we are a “good fit,” we will make a plan together that includes your goals for treatment.
Individual sessions typically last 50 minutes. Generally weekly therapy is helpful at the beginning of treatment, and may be recommended throughout treatment. Occasionally patients benefit from being seen more often, but this would be a conversation we would have together.
Risks and Benefits of Treatment: Mental health services are generally effective in treating most mental health conditions. Some few people do get worse from treatment. Improvement is not something that happens “to” a patient, it is a mutual effort undertaken by a therapist and patient together. Research indicates that one of the most important factor in an effective treatment is the relationship between the psychotherapist and patient.
Minors and Custody: My primary goal is to work with you to make a plan for your care that will help you make lasting improvements in your life. This is true for individual adult patients, it is also true for the teenagers I see.
I do not conduct custody evaluations, or determine whether or not an individual is “fit” to parent. I do not testify in court about custody concerns unless I am compelled to do so by subpoena.
It is important to note that both parents have equal access to their child’s medical and mental health records, regardless of who has custody of the child. This is true unless parental rights have been revoked by the court.
Minor Consent: A psychologist may provide treatment to a child who is 14 years or older in Oregon without the consent of a parent. Oregon law clearly states that a primary goal of this treatment should be to involve the parents before treatment ends, unless there are clear clinical reasons arguing against that involvement. Such arguments would include sexual abuse or emancipation.
If you are a minor signing this document, you authorize me to use my best judgment to decide whether I should contact your parents or not. You should also be aware that your parents will have the right to access your medical record, unless their parental rights have been revoked. This right continues until you have reached 18 years of age.
Your Rights & Responsibilities
Rights
You have the rights to
• Be treated with dignity and respect
• Participate in the development of your treatment plan , and choose from available services and supports that are consistent with the plan
o Participate in & assist in the development of the written plan
o Receive services consistent with that plan
o Participate in periodic review and reassessment of service and support needs
o Receive a copy of the written plan
• Have all services explained, including expected outcomes and possible risks;
• Obtain services in the most integrated setting in the community and under conditions that are least restrictive to your liberty, least intrusive to you and that provide for the greatest degree of independence
• Confidentiality, and the right to consent to disclosure in accordance with ORS 107.154, ORS 179.505, ORS 179.507, ; ORS 192.515, ORS 192.507, 42 CFR Part 2 and 45 CFR Part 205.50.
• Give informed consent in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law.
o Minor children may give informed consent to if under age 18 and lawfully married, age 16 or older and legally emancipated by the court, or age 14 or older
• Inspect your record in accordance with ORS 179.505;
• Not participate in experimentation
• Receive prior notice of service conclusion or transfer, unless it poses a threat to health and safety;
• Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation;
• Have religious freedom;
• Be informed at the start of services, and periodically thereafter, of the rights guaranteed by this rule;
• Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian, or representative, assist with understanding any information presented. A summary of policies is available upon request.
• Have family involvement in service planning and delivery;
• Make a declaration for mental health treatment, when legally an adult;
• File grievances, including appealing decisions resulting from the grievance;
• Exercise all rights set forth in ORS 109.610 through 109.697 if the individual is a child, as defined by these rules;
• Exercise all rights set forth in ORS 426.385 if the individual is committed to DHS; and
• Exercise all rights described in this rule without any form of reprisal or punishment.
Complaints & Grievances: If you are unhappy with my services, you have a right to file a complaint. You may do it informally by talking directly with me. You may also report your concerns to the Oregon Board of Psychologist Examiners www.oregon.gov/obpe or to the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington, DC 20201, or by calling 202-619-0257.
Your Responsibilities: You also have responsibilities as a patient. These include the following
· Cancellations and no-shows: I require a 48 business hour advanced notice for cancellations or re-schedules. Please call my office as soon as you are aware you will not be able to keep your appointment, to avoid being charged the full fee for your missed session.
· Payment of fee: You are responsible for paying your full fee for services at the time the services are rendered. I request that you bring a check to your appointment. Arrangements may also be made to pay by credit card or HSA card.
· Active participation in care: You have the responsibility to be an active participant in your care. Psychotherapy is not something that happens “to” you, it is an endeavor we will undertake together.
· Presumed termination of treatment:
o If you have not kept scheduled appointments and/or have not scheduled an appointment after 30 days, I will assume you are ending your treatment and will close your file.
o You may feel free to contact me to set an appointment to become an active patient again. I will do my best to schedule you in a timely manner,
Crisis and Emergencies: I do not provide emergency services. If you are in an acute emergency and you are unable to contact me directly, please call 911.
Oregon has a “warm line” where you may talk to peer counselors. You can use this if you need help with a crisis concern that does not involve risk of harm. That number is 1-800-698-2392.
A. Introduction: Information about HIPAA for my clients
This portion of the notice will tell you how I handle your medical information. It tells how I use this information here in this office, how I disclose (share) it with other health care professionals and organizations, and how you can see it. I want you to know all of this so that you can make the best decisions for yourself and your family. If you have any questions or want to know more about anything in this notice, please ask me for answers or explanations.
B. What I mean by your medical information
Each time you visit me or any doctor’s office, hospital, clinic, or other health care provider, information is collected about you and your physical and mental health. It may be information about your past, present, or future health or conditions, or the tests or treatment you got from me or from others, or about payment for health care. All this information is called “PHI,” which stands for “protected health information” which means its privacy must be protected. This information goes into your medical or health care records in my office.
In this office, your PHI is likely to include these kinds of information:
· Your history: Things that happened to you as a child; your school and work experiences; your marriage, relationships, and other personal history.
· Your medical history of problems and treatments.
· Reasons you came for treatment: Your problems, complaints, symptoms, or needs.
· Diagnoses: These are the medical terms for your problems or symptoms.
· A treatment plan: This is a list of the treatments and other services that I think will best help you.
· Progress notes: Each time you come in, I write down some things about how you are doing, what I notice about you, and what you tell me.
· Records I get from others who treated you or evaluated you.
· Psychological test scores, school records, and other evaluations and reports.
· Information about medications you took or are taking.
· Legal matters.
· Billing and insurance information
There may also be other kinds of information that go into your health care records here.
I use PHI for many purposes. For example, I may use it here:
· To plan your care and treatment.
· To decide how well our treatments are working for you.
· When I talk with other health care professionals who are also treating you, such as your family doctor or the professional who referred you to me. When I do this, I will ask for your consent. Almost always, I will also ask you to sign a release-of-information form, which will explain what information is to be shared and why.
· For teaching and training other health care professionals or for medical or psychological research. If i do this, your name will never be shown, and there will be no way they can find out who you are. Before I do this I will ask for your consent and ask you to sign an authorization, so that you will know what information will be shared and why.
· To show that you actually received services from me, for which I have provided you a superbill if you have requested one.
· For public health officials trying to improve health care in this area of the country.
· To improve the way I do my job by measuring the results of our work together.
When you understand what is in your record and what it is used for, you can make better decisions about what other persons or agencies should have this information, when, and why.
C. Privacy and the laws about privacy
I am required to tell you about privacy because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Omnibus Final Rule of 2013. HIPAA requires me to keep your PHI private and to give you this notice about my legal duties and my privacy practices.
This form is not legal advice. It is just to educate you about your rights and my procedures. It is based on current federal and state laws and might change if those laws or court decisions change. If I change my privacy practices, they will apply to all the PHI I keep. I will also post the new Notice of Privacy Practices in my office where everyone can see. You or anyone else can also get a copy from me. It is also posted on my website at ameliajwilcoxphd.com. I will obey the rules described in this notice.
D. How your protected health information (PHI) can be used and shared
Except in some special circumstances, when I use your PHI in this office or disclose it to others, I share only the minimum necessary PHI needed for those other people to do their jobs. The laws give you rights to know about your PHI, to know how it is used, and to have a say in how it is shared. So now I will tell you more about what I do with your information.
Mainly, I will use it here and disclose (share) your PHI for routine purposes to provide for your care, and I will explain more about these below. For other uses, I must tell you about them and ask you to sign a written Release of Information form. However, the HIPAA law also says that there are some uses and disclosures that don’t need your consent or authorization which I will explain below in section 3. However, in most cases I will explain the PHI and who it will go to and ask you to agree to this by signing a release-of-information form.
1. Uses and disclosures with your consent
I need information about you and your condition to provide care to you. In almost all cases, I intend to use your PHI here or share it with other people or organizations to provide treatment to you, arrange for payment for my services, or some other business functions called “health care operations.” You must agree to let me use and share your PHI in the ways that are described in this Notice of Privacy Practices. To agree, I will ask you to sign a separate consent form before I begin to treat you. If you do not consent to this, I will be unable to treat you because there is a risk of not helping you if I don’t have some information.
a. The basic uses and disclosures: For treatment, payment, and health care operations
Here I will tell you more about how your information will be used for these purposes.
For treatment. I use your information to provide you with psychological treatments or services. These might include individual therapy; psychological, educational, or vocational testing; treatment planning; or measuring the benefits of my services.
I may share your PHI with others who provide treatment to you. I usually try to share your information with your personal physician, unless you tell me not to. If you are being treated by a team, I can share some of your PHI with the team members, so that these providers will work best together. The other professionals treating you will also enter their findings, the actions they took, and their plans into your medical record, and so we all can decide what treatments work best for you and follow a treatment plan.
If I want to share your PHI with any other professionals, I will need your permission on a signed release-of-information form. For example, I may refer you to other professionals or consultants for services I cannot provide. When I do this, I need to tell them things about you and your conditions. Later I will get back their findings and opinions, and those will go into your records here. If you receive treatment in the future from other professionals, I can also share your PHI with them. I can do this only when you give your permission by signing a release-of-information form. This is so that you will know what information is being shared and with whom. These are some examples so that you can see how I use and disclose your PHI for treatment.
For payment. When you request it, I will use your information to provide you with a superbill, which you may use to seek partial reimbursement for our sessions. It is up to you to determine if your insurance will provide you with partial reimbursement, and if so, how much that reimbursement will be. If you choose to pursue reimbursement from your insurance for my services, that superbill will include information about your diagnoses, and the dates of treatment you have received. Your insurance company may contact me to find out about the changes I expect to see in your conditions. They may ask about when we met, your progress, and other similar things. Insurers may also look into a few of my patient records to evaluate the completeness of my record keeping.
For health care operations. Using or disclosing your PHI for health care operations goes beyond my care and payment for services. For example, I may use your PHI to see where I can make improvements in the care and services I provide. I may be required to supply some information to some government health agencies, so they can study disorders and treatment and make plans for services that are needed. If I do, your name and all personal information will be removed from what I send, and I will speak with you about it in advance.
b. Other uses and disclosures in health care
Appointment reminders. I may use and disclose your PHI to reschedule or remind you of appointments for treatment or other care. If you want me to call or write to you only at your home or your work, or you prefer some other way to reach you, we usually can arrange that. Just tell me what you prefer.
Treatment alternatives. I may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of help to you.
Other benefits and services. I may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
Research. I may use or share your PHI to do research to improve treatments—for example, comparing two treatments for the same disorder, to see which works better or faster. In all cases, your name, address, and other personal information will be removed from the information given to researchers. I will discuss this with you, and we will not use your PHI unless you give your consent on an authorization form. If the researchers need to know who you are, I will discuss the research project with you, and I will not send any information unless you sign a special release-of-information form.
Business associates. I hire other businesses to do some jobs for me. In the law, they are called my “business associates.” Examples may include a copy service to make copies of your health records, and a billing service to figure out, print, and mail my bills. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy, they have agreed in their contracts with me to safeguard your information just as I do.
2. Uses and disclosures that require your consent
If I want to use your information for any purpose besides those described above, I need your permission on a release-of-information form. If you do allow me to use or disclose your PHI, and then change your mind, you can cancel that permission in writing at any time. I will then stop using or disclosing your information for that purpose. Of course, I cannot take back any information used here already or disclosed to anyone with your permission.
As a psychologist licensed in Oregon, and as a member of Oregon Psychological Association, I maintain your privacy more carefully than is required by HIPAA. The HIPAA rules are described below, but I will almost always discuss these with you and ask you to sign a release of information so that you are fully informed.
3. Uses and disclosures that don’t require your consent or authorization
The HIPAA laws let medical and mental health professionals use and disclose some of your PHI without getting your consent or authorization in some cases. Here are some examples of when I might do this. I will almost always notify you if any of these situations occur.
a. When required by law
There are some federal, state, or local laws that require me to disclose PHI:
· I may have to report suspected abuse or neglect of children, elders and the disabled to DHS.
· If you are involved in a lawsuit or legal proceeding, and I receive a subpoena, discovery request, or other lawful process, I may have to release some of your PHI. I will only do so after telling you about the request and will suggest that you talk to your lawyer. We will review your record together before I send it to the requester, and I will ask you to sign a release-of-information, though I may be required to send your PHI, even if you choose not to sign a release.
· I have to disclose some information to the government agencies that check on my profession to see that I am obeying the privacy laws, and to organizations that review my work for quality and efficiency.
b. For law enforcement purposes
I may release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.
c. For public health activities
I may disclose some of your PHI to agencies that investigate diseases or injuries.
d. For matters relating to deceased persons
I may disclose PHI to coroners, medical examiners, or funeral directors, and to organizations relating to organ, eye, or tissue donations or transplants.
e. For specific government functions
I may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment. I may disclose your PHI to workers’ compensation and disability programs, to correctional facilities if you are an inmate, or to other government agencies for national security reasons.
f. To prevent a serious threat to health or safety
If I come to believe that there is a serious threat to your health or safety, or that of another person or the public, I can disclose some of your PHI. I will only do this to those people who can prevent the danger.
If it is an emergency, and I am unable to get your agreement, I can disclose information if I believe that it is what you would have wanted and if I believe it will help you. When I do share information in an emergency, I will tell you as soon as I can. If you don’t approve, I will stop, as long as it is not against the law.
4. Uses and disclosures where you have an opportunity to object
I can share some information about you with your family and anyone else you choose, such as close friends or clergy. I will ask you which persons you want me to tell, and what information you want me to tell them about your condition or treatment. You can tell me what you want, and I will honor your wishes as long as it is not against the law. Before I disclose this information, I will ask that you sign a release-of-information.
5. An accounting of disclosures we have made
When I disclose your PHI, I will keep a record of whom I sent it to, when I sent it, and what I sent. You can get an accounting (a list) of many of these disclosures. I may charge you a reasonable fee if you request more than one accounting in any 12-month period. If the records were sent as electronic medical records, I will always record that, and there will be no charge for an accounting.
E. Your rights about your protected health information
1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, rather than at work, to schedule or cancel an appointment. I will try my best to do as you ask, and I don’t need an explanation for such a request. Sending your information in emails has some risk that these emails could be read by someone else, and because of this, I do not send information beyond simple messages like changing appointments. I do not use it for any PHI or sensitive information and ask that you be thoughtful before you put any information you would prefer to keep private in an email. By signing the separate consent form, you agree to this use of email. Please note that anything you send me electronically becomes a part of your legal record, even if we do not place it in the chart. Be mindful of this, and please do not forward emails from third parties or others in your life. It is better to print those out and bring them in to discuss them.
2. You have the right to ask me to limit what I tell people involved in your care or with payment for your care, such as family members and friends. You can ask me face to face, and I may then ask for your written permission. I don’t have to agree to your request, but if I do agree, I will honor it except when it is against the law, when there is an emergency, or when the information is necessary to treat you.
3. You have the right to prevent my sharing your PHI with your insurer or payer for its decisions about your benefits or some other uses, if you pay directly (“out of pocket”) for treatment or other services and are not asking the insurer to pay for those services.
4. You have the right to look at your PHI, such as your medical and billing records. In some very unusual circumstances, if there is very strong evidence that reading this would cause serious harm to you or someone else, you may not be able to see all of the information. We would talk carefully about your record if you chose to review it.
5. You can get a copy of these records, but I may charge you a reasonable cost-based fee. If your records are in electronic form, not on paper, you can ask for an electronic copy of your PHI. Contact me to arrange how to see your records. Generally I do not recommend that you get a copy of your records, because the copy might be seen accidentally by others. I will be happy to review the records with you or provide a summary to you, or work out any other review method that satisfies you.
6. You have the right to add to (amend) your records to explain or correct anything in them. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your records or to include your own written statements to correct the situation. You must make this request in writing and send it to me. Your request will be included in your record, whether your record is amended or not.
7. You have the right to a copy of this notice. If I change this notice, I will post the new one in my waiting area, and have you sign one for your record.
8. If you have a problem with how your PHI has been handled, or if you believe your privacy rights have been violated, contact me. I will do my best to resolve any problems and do as you ask. You have the right to file a complaint with me, Oregon’s Board of Psychologist Examiners at www.oregon.gov/obpe, or with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington, DC 20201, or by calling 202-619-0257.
9. I will not in any way limit your care here or take any actions against you if you complain or request changes.
You may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. I will be happy to discuss these situations with you now or as they arise.
F. If you have questions or problems
If you have any questions about my health information privacy policies, please contact me at 503-490-5793.
The effective date of this notice is January 1, 2018