Notice of Privacy Practices for US Clients

 Annemarie Gockel, Ph.D., Psychologist, Health Service Provider (#9491); LICSW (#115087)

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to maintain the privacy of your protected health information (PHI), to provide you with this notice of my legal duties and privacy practices, and to abide by this notice. I reserve the right to change the terms of this notice of privacy practices at any time. Any new notice will be effective for all PHI I maintain at that time. I will provide you with a copy of the revised notice of privacy practices by posting a copy on my website, or providing a copy at your next appointment.

I. Confidentiality

As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, treatment goals and progress, topics we discuss, your medical, social and treatment history, copies of any screening or psychological testing reports, records I receive from other providers, a record of our communications and your billing records. I am required to retain a copy of your record for 5 years from your final date of service.

II. Limits to your confidentiality related to health care treatment, payment, and health care operations.

As a health care provider, I may legally use or disclose your PHI for treatment, payment, and health care operation purposes as discussed below:

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. An example of coordinating treatment would be when I consult with your family doctor or another mental health provider you are seeing about your care. Normally, I will ask for your written permission before consulting with another provider outside of my practice in a way that would identify you.

When I am away from my practice, I may provide you with the contact information for another provider who is covering the practice and responding to emergencies. If you reach out to that provider, they may access any and all information in your client record to respond to your immediate concerns.

For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you or to facilitate your reimbursement for services I have provided. 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. This also includes sharing such information as may be necessary with banking or financial services companies to facilitate payment for services. I may also use a collection service to collect payment 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 basic business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. Other business activities may include sharing your PHI with third parties that provide administrative or billing services, electronic records management services, or electronic booking services. In each case, I provide the minimum required information to accomplish the task at hand. Where possible, I sign written agreements with services that require them to safeguard the privacy of your PHI. 

III. Limits to your confidentiality related to state laws or my specific policies

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:

· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.

· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately and to provide relevant information to Department of Children and Families.

· Adult Abuse Reporting: If I have reason to suspect that an elder or a disabled adult is abused, neglected or exploited, I am required by law to immediately make a report and provide relevant information to the Office of Elder Affairs or to the Office of the Disabled Persons Protection Commission as appropriate.

· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. Although I will promptly inform you if I receive a subpoena for documents so that you may can take legal action on your own behalf, I will comply with any court order requiring the release of information.

· Serious Threat to Health or Safety: Under Massachusetts law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include: 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. The law also requires that I use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. This may include: 1) contacting a relative or support person, 2) notifying a law enforcement officer, or 3) seeking your hospitalization.

Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.

IV. Patient’s Rights and Provider’s Duties:

· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.

· 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. You may also request that I contact you only at work, or that I do not leave voice mail messages. To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

· Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization. On your written request, I will discuss with you the details of the accounting process. I may charge a reasonable fee if you request more than one accounting in any 12-month period.

· Breach Notification – If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.

· Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may also refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.

· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.

· Right to a copy of this notice – You have the right to a paper copy of this notice, even if you have agreed to receive the notice electronically. You may ask me to give you a copy of this notice at any time.

· Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.

EFFECTIVE DATE: May 24, 2021