Michelle Schmidt, NCC, LPC
33 South Main Street
Mullica Hill, NJ 08062
(856) 418-1950
To my clients: I am required to give this notice to you under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how psychological/medical information about you may be used and disclosed, and how you can get access to this information.
Please review it carefully.
1. Uses and Disclosures for Treatment, Payment, and Health Care Operations Your Protected Health Information (PHI) is any information about your past, present, or future physical or mental health conditions or treatment, or any other information that could identify you. By signing this form, you are giving consent for me to “use” your PHI within my practice or “disclose” your PHI to an outside entity for the following purposes:
1 Treatment: providing, coordinating, or managing your health care and other services related to your health care. An example would be when I consult with another health care provider, such as your family physician.
2 Payment: obtaining reimbursement for your healthcare. Examples include when I disclose your PHI to your health insurer to help you obtain reimbursement for your health care.
3 Health Care Operations: activities that relate to the performance and operation of my practice, such as clinical peer review, depositing of checks to my business account, or audits to my business.
4 Note: if a child turns 14 years old and can then legally consent to treatment themselves, unless they indicate otherwise, I will assume their ongoing consent.
II. Uses and Disclosure Requiring Authorization Outside of routine treatment, payment, and health care operations, I will not release your PHI unless you sign an Authorization Form authorizing that specific disclosure. I would also need to obtain your authorization before releasing your ”Psychotherapy Notes” to anyone with certain exceptions required by law. You may revoke an authorization to the extent that (1) I have already released information based on that authorization; or (2) 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: I may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If I have reasonable cause to believe that a child has suffered abuse or neglect, I am required by law to report it to the proper law enforcement authorities. Adult and Domestic Abuse: If I have reasonable cause to believe that abandonment, abuse, financial exploitation, sexual or physical assault, or neglect of a vulnerable adult has occurred, I must immediately report it to the appropriate authorities. Health Oversight: If the State Department of Health subpoenas your therapist as part of “Notice of Privacy Practices Regarding Protected Health Information,” its investigation, hearings, or proceedings relating to the discipline, issuance, or denial of licensure to a therapist. This could include disclosing your relevant mental health information. Judicial or Administrative Proceedings: If you are involved in a court proceeding, I will release information only with the written authorization of you/your legal representative, or a court order. I will not release information for a subpoena without your permission-you may claim this as privileged communication and I will assert confidentiality of these records. (This privilege does not apply when you are being evaluated for a third party or for the court. You will be informed in advance in this is the case). Serious Threat to Health or Safety: I may disclose your mental health information to any person without authorization if I reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. Workers Compensation: If you file a worker’s compensation claim, I must make all mental health information in my possession that is relevant to the injury available to your employer, your representative, and the Department of Labor and Industries upon their request.
IV. Patient Rights: Rights to Request Restrictions: You have the right to request restrictions on specific uses and/or disclosures of your PHI. However, I am not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means at Alternative Locations: You have to right to request and receive confidential communications of PHI by alternative means and at alternative locations (for example, only calling you at work). Rights to Inspect and Copy: You have the right to inspect and /or obtain a copy of PHI under certain circumstances, but in some cases you have this decision reviewed. Rights to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request if I believe the original information is accurate. Right to an Accounting of Disclosure: You have the right to receive a list of this disclosure that I have made of your PHI. Some exceptions do apply.
V. Therapist Duties: I am required by law to maintain the privacy of your PHI and to provide you with this 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 by mail of changes, I am required to abide by the terms in this Notice.
VI. Complains: If you have a complaint about the way I have handled your privacy rights, you may contact: Division of Consumer Affairs, State Board of Marriage and Family Therapy Examiners
Address: 124 Halsey Street, 6th Floor, P.O. Box 45007, Newark, New Jersey 07101
Phone: (973) 504-6415
I have read the above Notice, understand its content.
Client’s signature: _________________________________________________________________________ Date: ____________________________________________________
Client Representative and relationship to client: ___________________________________________ Date: _____________________________________________________