Notice of Privacy Practices for Protected Health Information by os8lO1GE


									                       UNM Department of Psychology Clinic
           Brief Summary of Client Rights to Privacy and Access to Records
                 Consent to Behavioral Health Treatment or Evaluation

Name:______________________________________________________________ SSN___________________


Phone: Home___________________________ Work _____________________ E-mail__________________
It IS / IS NOT okay to leave messages at my home number.
It IS / IS NOT okay to contact me at work
Other contact instructions:

Date of birth___________________________________ Referred by ________________________________

Typical annual income _____________ Fee ____________ To be paid by __________________________

The remainder of this document
     lists the kind of behavioral health services you will be receiving at the UNM Department
       of Psychology Clinic
     describes the confidentiality of your services and the privacy of your records
     advises you about the few exceptions to confidentiality
     tells you about how you can get access to your records, and
     allows you to consent to these services with the rights and limitations described
More information is available in the document Protecting the Privacy of Your Behavioral Health
Information which you will be shown and may have a copy of.

Section I. Type of behavioral health services and limits on confidentiality
The UNM Department of Psychology Clinic (the Clinic) agrees to provide me with the following
behavioral health services (choose either a or b; the client age 14 and older and a
representative of the Clinic should initial on the appropriate line):

  Client   Clinic

a. _______ ______ Psychotherapy, counseling, evaluation or substance abuse treatment with
                  full privacy of behavioral health information as described in this document
                  (cross through the lines below)

b._______ ______ Behavioral health services with limits on confidentiality which have been
                 described to me and listed here:

                                                              Client initials for page   1______
Section II. Your privacy rights
A. Protection of Behavioral Health Information
Our pledge to you is that, except for special circumstances explained below, we will not reveal
behavioral health information to others outside the treatment setting without your
consent and authorization. This pledge is based on and supported by New Mexico and federal
law and regulations, and by court opinion and rules. In particular, it is supported by the
Health Insurance Portability and Accountability Act (HIPAA), which requires that we inform you
of your rights to privacy and access.

B. Protected Behavioral Health Information and Other Definitions
Definitions of “protected behavioral health information” and “psychotherapy notes” follow.
Definitions of other terms may be found in the document Protecting the Privacy of Your
Behavioral Health Information.

“Protected behavioral health information” is all of the information,
     from you or about you,
     obtained in conversation or writing,
     held in memory or written down,
     learned by behavioral health professionals, student clinicians or Clinic staff,
     learned in the course of assessment or treatment for mental or emotional problems,
       substance abuse issues or problems in living,
     including the opinions, diagnoses and assessments that the behavioral health
       professional or their supervisees develop based on the information you give them.

“Psychotherapy notes” are special notes that are kept by psychotherapists for their own
purposes. These notes are available only to the clinician who made them, those involved in
their supervision, or a consultant. They are not available to health insurers or to patients.

C. Who knows protected behavioral health information at the Clinic?
The following individuals will know some of your protected behavioral health information within
the context of your treatment at the Clinic.
     Your primary clinician.
     Members of a treatment team if your therapist or evaluator is working with others on
        your case. At a minimum, the Director of the Clinic is involved directly or indirectly in
        all cases.
     Supervisors of your primary clinician, who are faculty or professional staff of the UNM
        Department of Psychology, and students who are learning to provide treatment with the
        same supervisor.
     Administrative and office staff who handle files, type reports, do billing operations, greet
        people and do the daily work in the treatment setting. These people are trained by and
        work under the supervision of the treating professionals.
     Quality control people who review files to see that they are being kept properly and that
        treatment is being carried out appropriately.
     Behavioral health professionals who provide case consultation.

D. Uses and Disclosures Requiring Authorization
We will need your written permission and authorization before we can release your protected
behavioral health information to others outside the Clinic. We will first make sure that you
know what will be disclosed and why and that you are not under undue pressure to sign.
Then, we will disclose information to others with your signed authorization.

                                                                 Client initials for page   2______
E. Critical situations in which your authorization is not required
In critical situations, we will reveal protected behavioral health information without your
permission or authorization. These are situations where disclosure is required by law or court
cases, but we also respect and support these legal requirements and willingly obey them.
     Abuse of a child or an incapacitated adult.
     Serious Threat to Health or Safety of you or someone else.
     Threat to National Security: HIPAA regulations list this as a separate critical situation,
         but it appears to be a special case of danger to others.

F. Disclosing protected behavioral health information for payment purposes
Another person, agency or organization may be paying part of your healthcare expenses. The
fact that they are paying does not entitle them to access to all of your protected health
information. However, they may legitimately require some of your protected behavioral health
information in order to determine whether they will pay for it, and how much they will pay. We
will limit the amount of information disclosed to a payer to the minimum necessary to serve the
purpose. See also the next section on Hidden Permission.

G. Hidden permission
The following are some examples of situations where you may be giving your permission to
release your protected behavioral health information while you are trying to accomplish another
     Payment for and authorizing of services, usually in a managed care situation. To be
        clear, there are sometimes disagreements between payers and providers about how
        much ought to be shared for this purpose. HIPAA has set up new and better limits
        about how much must be disclosed for payment, making it easier for providers to limit
        what will be shared.
     If you file a worker’s compensation claim, you are giving permission for health
        information about you to be used in evaluating this claim.
     If you file a lawsuit, and claim that part of your injuries and damages were emotional or
        that you experienced “pain and suffering,” we are required to obey a court order asking
        that we disclose information or testify.
     If you bring a case against us in a lawsuit or in a complaint to the licensing board of one of
        your treatment team, we are required to obey a court order or licensing board subpoena
        and are allowed to use such information to defend ourselves.
     When you are being evaluated and the purpose is to provide information to someone else
        (for example, an employee screening, education-related testing or a court-ordered
        evaluation). We will always let you know if this applies in your case, for instance, by
        choosing “b” in the first section and writing the limitations on confidentiality.

H. Confidentiality is quite broad
With all these exceptions, it is worth repeating that in most cases we are allowed and required
to protect your behavioral health information so that you will feel safe discussing private and
personal matters. We will fight court orders or subpoenas that ask us to reveal protected
behavioral health information without your authorization and we expect to win based on state
and federal law and court cases. We will not reveal protected behavioral health information to
family members of clients age 14 and over. Other examples of the kinds of things that are
protected are listed in the document Protecting the Privacy of Your Behavioral Health

Section III. Your Rights to Understand and Control Your Records
You have the right to know what is in your records, and in most cases to add corrections to
your file. As usual, there are some exceptions and details; only the general points are listed
here. We are glad to discuss with you the details of the rights listed here. You have the right:
    to inspect and copy your records except psychotherapy notes

                                                                  Client initials for page   3______
      to amend You have the right to request an amendment or correction of the behavioral
       health information in your file. In some cases we are allowed to deny your request and
       you may ask one of the sources below (see Section VI: Complaints) whether you can
       overturn our decision.
      to know what has been disclosed
      to request restrictions on certain uses and disclosures of protected behavioral health
       information, which we will usually comply with.
      to receive confidential communications by alternative means and at alternative locations,
       for instance, to keep a family member or roommate from knowing that you are receiving
      to a paper copy of Protecting the Privacy of Your Behavioral Health Information and to be
       informed if it changes.

Section IV. Complaints
If you are ever concerned that we have violated your privacy rights, or you disagree with a
decision we have made about access to your records, you may contact any of the following:
 The licensing board for your primary clinician or that person’s supervisor, or
 UNMHSC Privacy Officer
    phone: (505) 272-2121
    fax: (505) 272-1827
    TDD: UNM Hospital Operator (505) 272-2111, or
 You may also send a written complaint to the Secretary of the U.S. Department of Health
    and Human Services. The person listed above can provide you with the appropriate address
    upon request.

Section V: Consent for treatment
Please circle choices (in capital letters in Item 3) and initial each item which is true for you:

1. _______ I have been shown the document Protecting the Privacy of Your Behavioral Health
           Information and have been offered a copy of it.
2. ________I have had an opportunity to ask any questions about the privacy of my treatment
           and my access to records.
3. ________I AM / AM NOT receiving physical health treatment and HAVE / HAVE NOT been
           shown the UNMHSC Notification of Privacy Practices.
3. _______ I understand that my clinician may keep psychotherapy notes as defined above to
           which I will not have access.
4. _______ I agree to be audiotaped or videotaped for purposes of supervision with the
           understanding that the tapes are treated with the privacy described in this
           document (if you choose not to be taped, we will attempt to assign you to a clinician
           and supervisor who do not require it).

I consent to treatment, evaluation or both under these rules regarding my rights to privacy and
access to my records.

______________________________________________        __________________________________________
Person receiving services (or parent if under 14)     Representative of the Clinic

_________________________                             ___________________________
Date                                                  Date

                                                                   Client initials for page   4______

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