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

OUR LEGAL DUTY
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is a federal regulation implemented to ensure privacy protections and patient rights with regard to the use and disclosure of Protected Health Information (PHI). This Notice of Privacy Practices (the “Notice”) is meant to inform you of the ways we may use or disclose your protected health information. It also describes your rights to access and control your protected health information and certain obligations we have regarding use and disclosure of your protected health information.

In compliance with HIPAA, CatholicPsych Institute has developed an Informed Consent and Notice form which outline your rights and responsibilities. The law requires that you sign an acknowledgment that you have been provided with this information.

We may revise our Notice at any time. The new revised Notice will apply to all of your protected health information maintained by us. You will not automatically receive a revised Notice. If you would like to receive a copy of any revised Notice, please request a copy.


I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
CatholicPsych Institute (hereafter CPI) 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 your psychologist/counselor provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your psychologist/counselor consults with another health care provider. However, CPI requires a separate authorization to disclose your PHI outside of our organization for the purpose of treatment.
– Payment is when CPI obtains reimbursement for your healthcare or submits information for reimbursement on your behalf. Examples of payment are when your PHI is disclosed 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 CPI. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination activities. These activities may include protective services for the President, Director, and others.
· Use applies only to activities within CPI such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· Disclosure applies to activities outside the CPI such as releasing, transferring, or providing access to information about you to other parties.

II. USES AND DISCLOSURES REQUIRING AUTHORIZATION
CPI 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. For example, your psychologist/counselor may want to consult with another health care provider outside of CPI, such as your family physician, another psychologist/counselor, or a spiritual director. In those instances when your psychologist/counselor is asked for information for purposes outside of treatment, payment or health care operations, they will obtain an authorization from you before releasing this information. They will also need to obtain an authorization before releasing your psychotherapy notes.

Psychotherapy notes are notes about conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. 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 CPI has relied on that authorization; or 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.

III. USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION
CPI is required or permitted to use or disclose your PHI without your consent or authorization in the following circumstances (as permitted by the HIPAA Privacy Regulation).
· Child Abuse – When there is reasonable cause to believe that a child has been subjected to abuse or neglect, or if your psychologist/counselor observes a child being subjected to conditions which would reasonably result in abuse or neglect, CPI must report this to the proper law enforcement agency or protective service agency.
· Adult and Domestic Abuse – When there is reasonable cause to believe that a vulnerable adult has been subjected to abuse or if your psychologist/counselor observes such an adult being subjected to conditions which would reasonably result in abuse, CPI must report this to the appropriate law enforcement agency or protective service agency. (A “vulnerable adult” is any person eighteen years of age or older who has a substantial mental or functional impairment or for whom a guardian has been appointed)
· Health Oversight Activities – We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections.
· 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. CPI will not release information without a court order or without the written authorization from you or your personal or legally appointed representative. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety – If you communicate a serious threat of physical violence against a reasonably identifiable victim or victims, CPI must communicate such threat to the victim or victims and to a law enforcement agency.
· Worker’s Compensation – If you file a worker’s compensation claim, CPI must, on demand, make available records relevant to that claim to your employer, the insurance carrier, the worker’s compensation court, and to you.
· Disclosures to You – CPI is required to provide your PHI to you upon request or to provide you with the PHI of any individual on whose behalf you are acting as a personal representative.
· Business Associates – CPI contracts with individuals and entities (business associates) to perform various functions on our behalf or to provide certain types of services. To perform these functions or to provide the services, business associates will receive, create, maintain, use, or disclose your PHI. CPI requires business associates to agree in writing to contract terms designed to appropriately safeguard your PHI.
· National Security Matters – We may use and disclose your health information without your authorization to authorized Federal officials for the purpose of conducting national security and intelligence
· As Required By Law – We will disclose health information about you when required to do so by federal, state, or local law.

There may be additional disclosures of PHI that CPI is required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.

IV. PATIENT’S RIGHTS AND PSYCHOLOGIST/COUNSELOR’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. This request must be in writing. (However, CPI is 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. This request must be in writing. (For example, you may not want a family member to know that you are being seen by our psychologist/counselor. At your request, your bills will be sent to another address).
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. This request must be in writing. (You may be denied access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. There is no right of review of the denial of access to psychotherapy notes. At your request, your psychologist/counselor 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. Your request may be denied. This request must be in writing. (At your request, your psychologist/counselor 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 III of this Notice). This request must be in writing. At your request, your psychologist/counselor 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 this Notice upon request, even if you have agreed to receive the Notice electronically.
· File a Complaint with us or with the Secretary of Health and Human Services
Psychologist/Counselor’s Duties:
· CPI is required by law to maintain the privacy of PHI, to provide you with a notice of our legal duties and privacy practices with respect to PHI, to follow the privacy practices that are described in this Notice while it is in effect, and to obtain your signature acknowledging your receipt of this Notice. This Notice takes effect January 1, 2016 and will remain in effect until we replace it.
· CPI reserves the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. Unless you are notified of such changes, CPI is required to abide by the terms currently in effect.
· CPI reserves the right to make changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes.
· If CPI revises its Notice of Privacy Practices, active clients will receive a revised copy of the Notice at the first session held after the revisions are made. It will be noted in the file that the revised notice was offered and/or received. The effective date of the notice will appear at the end of the notice.

V. QUESTIONS AND COMPLAINTS
· If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your health information, or in response to a request you made to amend or restrict the use or disclosure of your health information, or to have us communicate with you by alternative means or at alternative locations, you may contact Gregory Bottaro, Psy.D., Director: (347)-705-0406, the State of Connecticut, Department of Mental Health and Addiction Services (DMHAS), Privacy Officer at (860) 418-6901, or the Secretary of the United States Department of Health and Human Services (DHHS), Office for Civil Rights (OCR) at: U.S. DHHS, OCR, J.F. Kennedy Federal Building – Room 1875, Boston, Massachusetts 02203. Voice phone: (617) 565-1340. TDD: (617) 565-1343. FAX: (617) 565-3809.
· We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us, with DORA, or with the U.S. Department of Health and Human Services.