HAWAII NOTICE FORM
Notice of Policies and Practices to Protect the Privacy of Patient Health Information
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.
I. Uses and Disclosures for Treatment. Payment. and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. 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 I provide, coordinate, or manage your health care and other services related to your health care . An example of treatment would be when your provider consults with another health care provider, such as your family physician or another psychologist.
-Payment is when I obtain reimbursement for your healthcare. Examples of payment I when I disclose your PHI 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 the practice. 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.
• "Use" applies only to activities within the [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.
• "Authorization" is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.
II. Other Uses and Disclosures Requiring Authorization
EHS,LLC may use or disclose PHI for purposes outside of treatment , payment , or health care operations when your appropriate authorization is obtained. In those instances when EHS, LLC. is asked for information for purposes outside of treatment, payment, or health care operations, EHS, LLC. will obtain an authorization form from you before releasing this information. EHS, LLC. will also need to obtain an authorization before releasing your Psychotherapy Notes .
"Psychotherapy Notes" are notes your provider may have made about a 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 (1) We have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures without Authorization EHS,LLC may use or disclose PHI without your consent or authorization in the following Circumstances:
•Child Abuse - If your provider may have reason to believe that a child has been subjected to abuse or neglect, they must report this belief to the appropriate authorities.
•Serious Threat to Health or Safety - If you communicate to your provider a specific threat of imminent harm against another individual or if your provider believes that there is clear , imminent risk of physical or mental injury being inflicted against another individual , theymay make disclosure s that are believed necessary to protect that individual from harm . If your provider believes that you present an imminent, serious risk of physical or mental injury or death to yourself, they may make disclosures considered necessary to protect you from harm.
The Federal rule prohibits EHS,LLC. from making any further disclosure of the information unless further disclosure is expressly permitted by the written consent of the person to who it pertains, or as other permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient
IV. Patient's Rights and Psychologist'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. However, EHS,LLC. 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. (For example, you may not want a family member to know that you are seeking treatment. On your request, EHS,LLC. will send your bills to another address).
•Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. EHS, LLC. may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.
•Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. EHS, LLC. may deny your request. On your request, your provider 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. On your request, your provider 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 the notice from EHS, LLC. upon request, even if you have agreed to receive the notice electronically.
Therapist’s Duties:
•I am required by law to maintain the privacy of PHI and to provide you with a 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 of such changes, however, I am required to abide by the terms currently in effect.
•If I revise my policies and procedures, I will provide you with the revised notice either in person or by mail and request that you review and re-sign the form acknowledging and consenting to the changes.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision your provider makes about access to your records, or have other concerns about your privacy rights, you may contact the sole proprietor of EHS, LLC. , JoMarie Tyrrell LMFT, CSAC 808-757-8910.
If you believe that your privacy right s have been violated and wish to file a complaint with my office, you may send your written complaint to JoMarie Tyrrell c/o Empowered Health Services, LLC. 810 Kokomo Rd. STE 245AHaiku, HI96708.
You may also send a written complaint to State of Hawaii Regulated Industries Complaints Office, Department of Commerce and Consumer Affairs, Leiopapa A Kamehameha Building, 235 South Beretania Street, Ninth Floor, Honolulu, Hawaii 96813
You have specific rights under the Privacy Rule and BHH will not retaliate against you for exercising the right to file a complaint.
VI. Effective Date. Restriction. and Changes to Privacy Policy
This notice is effective as of January 1, 2016. EHS, LLC. reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that is maintained. EHS, LLC. will provide you with a revised notice in person or by mail.
Acknowledgement of Receipt of HIPAA Notice of Privacy Practices Form
The Health Insurance Portability and Accountability Act (HIPAA) , a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that EHS, LLC. provides you with a Notice of Privacy Practices (the Notice) for use and
disclosure of PHI for treatment , payment and health care operations. The Notice, which is attached, explains HIPAA and its application to your personal health information in greater detail. The law requires that BHH obtains your signature acknowledging that EHS, LLC. has provided you with this information.
It is very important that you read this notice carefully before your first session. Any questions are welcomed at that time.
CONSENT AND DISCLOSURE
Degree and License: I have a Master of Arts degree in Marriage and Family Therapy, and I am licensed by the State of Hawai’i as a Marriage & Family Therapist.
Patient Confidentiality: Information received by a psychotherapist from the client(s) during the course of treatment and all information about the client(s) that is obtained is confidential and may not be released without a signed authorization form to release such information. *Parents should note that minors who have attained the age of twelve are entitled to confidentiality, and confidentiality applies to minors of all ages when revealing information about the minor could be damaging to the minor’s progress in therapy. Information obtained from family members attending collateral visits wherein a patient is discussed is not confidential from the client(s).
*Exceptions: 1) The State of Hawai’i mandates that I report known or suspected child abuse and elder abuse. 2) The State of Hawai’i gives me the right to break confidentiality if a client is a danger to him/herself or to the person or property of another. 3) Uses and disclosures relating to Treatment, Payment, or Health Care Operations (TPO). 4) Managed care companies may review clinical records for purposes of quality assessment.
Psychotherapist-patient privilege: As a Marriage & Family Therapist, I am covered by the psychotherapist-patient privilege in any legal proceeding in the State of Hawai’i. Privilege involves the right to withhold testimony or records in a legal proceeding unless the psychotherapist has reasonable cause to believe that the patient is a danger to him/herself or to the person or property of another and that disclosure of thecommunication is necessary to prevent the threatened danger. Under certain circumstances the court (judge) may overturn this privilege.
Emergency: If I cannot be reached in an emergency, call 911 or the Access line at 1-800-753-6879 (available 24/7).
As a client, you can terminate therapy at any time. I hold the option of terminating therapy if your account falls too far in arrears, if I think you are not benefiting from therapy with me, or if another practitioner could deal with your issue more appropriately. In that situation, I will refer you to another therapist.
Missed appointments: Your appointment has been reserved just for you. Twenty-four (24) hours notice is required for cancellation of all appointments. Otherwise, you will be charged the full fee for the missed appointment. The payment of this fee is your responsibility and most probably will not be reimbursed by the insurance company. This can be waived at my discretion.
*I understand the policy for missed appointments. (Initial)_______________
Consent for Treatment: I authorize and request my therapist to carry out individual, couple or family therapy methods, which during the course of treatment become advisable. I understand the purpose of these methods will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my treatment is designed to be helpful, my therapist can make no guarantees about the outcome of my treatment. Further, the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, and anger. I understand that this is a normal response to working through unresolved life experiences, and that these reactions will be worked on between my therapist and me.
I acknowledge that I have received a copy of the Notice of Policies and Practices to Protect the Privacy of Patient Health Information, effective January 1, 2016
Print Name__________________________________________________________
Signature _______________________________________________________________
Date ____________________________________________________________
Court Testimony
Empowered Health Services, LLC and JoMarie Tyrrell, LMFT does not perform court-related evaluations for child custody nor do we testify in hearings involving child custody issues. In addition, we do not appear voluntarily at any court or administrative hearing. It is not in your best interest to ask that I or anyone associated with Empowered Health Services, LLC testify for you, no matter what issue is involved. If you, or your attorney, choose to subpoena me or any other Empowered Health Services, LLC
personnel for court testimony, including depositions or administrative hearings, you will be charged $150 per hour for any preparation time I or other personnel spend getting ready to appear, and $750 per 4 hour block of time that I or other personnel spend being “on call” to testify, traveling to and from court, waiting to appear, and/or testifying. The minimum charge will be for 4 hours of time and subsequent time will be billed in 4 hour blocks. The initial $750 is due in full one week prior to any scheduled court appearance. By signing this agreement, you agree to pay these charges. Should it become necessary for me to commence collection proceedings or retain an attorney to collect any fees due hereunder, you agree to pay the attorney’s fees and costs of collection incurred by me and/or Empowered Health Services, LLC.
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Signature Date