Notice of Privacy
Practices
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.
Purpose
James Rosen, Ph.D.,P.A. follows the privacy
practices described in this Notice. Dr. Rosen keeps your psychological
and medical information in records that are maintained and protected in
a confidential manner, as required by law.
What Kinds Of Mental Health Information
Will Be Collected?
The information Dr. Rosen collects from
you is called Protected Health Information (PHI), and it goes into your
healthcare record in the office. In Dr. Rosen's office, your PHI
may include:
-
The reasons you came for treatment, such as
problems, symptoms, needs and goals
-
Dr. Rosen's general observations of your problem
areas, symptoms, and level of functioning
-
Information that you or your medical doctor
provide about your prescribed medications, medical appointments, and medical
tests
-
Dr. Rosen's assessment of your symptoms and
diagnoses
-
The treatment plan that Dr. Rosen believes
will best help you, including psychotherapy "homework" that he assigns
to you
-
The psychotherapy methods which Dr. Rosen
employs in your treatment, and the general problem areas that you are working
on
-
Your verbal reports of your progress, and
Dr. Rosen's observations of your progress
-
Records from others who treated or evaluated
you
-
Psychological test results, school records,
etc.
-
Insurance statements and insurance information
How Will Dr. Rosen Use Your Protected Health
Information (PHI)?
Your personal health record will be retained
by James Rosen, Ph.D.,P.A. for ten years after your last clinical contact
with him. After that time has elapsed, the record will be shredded
or burned or otherwise destroyed in a way that protects your privacy.
Until the records are destroyed, they may be used for three (3) purposes:
treatment, payment, or healthcare operations. When Dr. Rosen discloses
your PHI to others, he will share only the minimum necessary PHI to accomplish
these purposes.
What Are The Treatment, Payment, And
Healthcare Operations?
Unless you ask for restrictions on a specific
use or disclosure, your PHI may be used for the following:
-
To schedule your appointments
-
To plan your treatment
-
To communicate with other healthcare providers
who are also treating you
-
To file insurance claims, and to show that
you received the services that you or your insurance company are billed
for
-
As may be required by law
-
For law enforcement officials to investigate
a crime
-
For public health activities
-
To prevent a serious threat to health or safety,
for instance in the reporting of suspected child abuse or imminent threats
of physical harm to oneself or another person
-
If you are involved in a lawsuit or legal
proceeding and Dr. Rosen receives a subpoena (Dr. Rosen will attempt to
provide you advance notice of subpoena before disclosing information from
your record.)
-
To military command authorities if you are
a member of the armed forces or a member of a foreign military authority
-
For national security and intelligence activities
-
To comply with laws relating to worker’s compensation
or other similar programs, that provide benefits for work-related injuries
or illness without regard to fault
For Other Disclosures, Your Authorization
Is Required
Except as described above, Dr. Rosen will
not use or disclose information from your record unless you authorize him
in writing to do so. You may revoke your authorization, which will
be effective only after the date of your written revocation.
You Have Rights Regarding Your Protected
Health Information (PHI)
You have the following rights regarding
your PHI, provided that you make a written request to invoke the right:
-
Right to request restriction.
You may request limitations on the psychological and medical information
that is disclosed, but Dr. Rosen is not required to agree to your request.
If he agrees, he will comply with your request unless the information is
needed to provide you with emergency treatment.
-
Right to confidential communications.
You may request communications in a certain way or at a certain location,
but you must specify how or where you wish to be contacted.
-
Right to inspect and copy. You
have the right to inspect and copy your protected health information (PHI).
However, psychotherapy notes are not part of your PHI and may not be inspected
and copied. Dr. Rosen may charge a fee for copying, mailing, and
supplies. Under limited circumstances, your request may be denied.
If so, you may ask for a review of the denial by another licensed mental
health professional chosen by Dr. Rosen. Dr. Rosen will comply with
the outcome of the review.
-
Right to request clarification of record.
If you believe that the information Dr. Rosen has about you is incorrect
or incomplete, you may ask to add clarifying information. You may
ask for a form for that purpose, and the form will require certain specific
information. Dr. Rosen is not required to accept the information
that you propose.
-
Right to accounting of disclosures.
You may request a list of the disclosures of your PHI that have been made
for other than treatment, payment, or health care operations in the last
six (6) years, but not prior to April 14, 2003.
-
Right to a copy of this Notice.
At your request, Dr. Rosen will provide you with a paper copy of this Notice
at any time. You may also print out a copy of this notice from Dr.
Rosen's web site, www.reachingup.com.
Requirements Regarding This Notice
Dr. Rosen is required to provide you with
this Notice that governs his privacy practices. He may change his
policies or procedures in regard to privacy practices. If and when
changes occur, the changes will be effective for psychological and medical
information he has about you as well as any information he receives in
the future. Any time you telephone Dr. Rosen or come to his office,
you may ask for and receive a copy of the Notice of Privacy Practices that
is in effect at the time. The current Notice will also be posted
on Dr. Rosen's web site, www.reachingup.com.
Complaints
If you believe your privacy rights have
been violated, you may file a complaint with Dr. Rosen, or with the office
of the Secretary of the U.S. Department of Health and Human Services.
You will not be penalized or retaliated against in any way for making a
complaint.
Contact
Call Total Health Psychology (at 501-623-2050)
and ask to speak to Dr. Rosen if:
- You have a complaint
- You have any questions about
this notice
- You wish to request restrictions
on use and disclosure of your protected health information for purposes
of treatment, payment or health care operations
- You wish to obtain any of the
forms mentioned to exercise your individual rights described above
This Notice of Privacy Practices published:
04/21/03