Notice of Privacy Practices

Notice of Therapists’ Policies and Practices to Protect the Privacy of Your 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

Your therapist 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.

  • “Therapist” refers to any licensed mental health professional.

  • “Treatment, Payment and Health Care Operations”

    • Treatment is when your therapist provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another psychotherapist.

    • Payment is when your therapist obtains reimbursement for your healthcare. Examples of payment are when your therapist discloses 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 this 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 this practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

  • "Disclosure" applies to activities outside of this practice, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Your therapist 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. In those instances when your therapist is asked for information for purposes outside of treatment, payment or health care operations, your therapist will obtain an authorization from you before releasing this information. Your therapist will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes your therapist may have made about your conversation during a private, group, joint, or family counseling session, which have been 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) your therapist has relied 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

Your therapist may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If your therapist knows or has reason to believe a child is being or has been neglected or abused, or that a child has been threatened with neglect or abuse that is likely to occur, he or she must immediately report the information to the relevant county department, police, or sheriff's department.

  • Vulnerable Adult Abuse:  If your therapist has reason to believe that a vulnerable adult is being or has been maltreated, abused, or neglected, or has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained, your therapist must immediately report the information to the appropriate agency in this county. Your therapist may also report the information to a law enforcement agency. 

    • Vulnerable Adult means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction (i) that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and (ii) because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment.

  • Health Oversight: If the Wisconsin Department of Regulation and Licensing requests that your therapist releases records to them in order for the appropriate examining board to investigate a complaint, he or she must comply with such a request.

  • Judicial or 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 and your therapist will not release the information without written authorization from you or your personal or legally-appointed representative, or a court order. 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 your therapist has reason to believe that you may cause harm to yourself or another person, he or she must make a reasonable effort to warn the third party (if any) and/or contact law enforcement.

  • Worker’s Compensation: If you file a worker’s compensation claim, your therapist may be required to release records relevant to that claim to your employer or its insurer.

IV. Patient’s Rights and Psychotherapist’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, your therapist 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 seeing a therapist. On your request, your therapist 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 the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, your therapist 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 therapist may deny your request. On your request,  your therapist 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 regarding you. On your request, your therapist 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 from your therapist upon request, even if you have agreed to receive the notice electronically.

Psychotherapist’s Duties: 

  • Your therapist is required by law to maintain the privacy of PHI and to provide you with a notice of his or her legal duties and privacy practices with respect to PHI.

  • Your therapist reserves the right to change the privacy policies and practices described in this notice. Unless he or she notifies you of such changes, however, your therapist is required to abide by the terms currently in effect.

  • If your therapist revises his or her policies and procedures, you will be provided with a copy of the revised version at your next scheduled therapy session. 

V. Complaints

If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision made by your therapist about access to your records, you may further discuss this with your therapist. If you are not satisfied, please contact Brian Crim, LMFT (HIPAA Security Officer) at 715-410-5822.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints or the applicable state board of your therapist. 

VI. Effective Date, Restrictions and Changes to Privacy Policy 

This notice is effective April 13, 2003. Adulteen Counseling, LLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. If this should take place, Adulteen Counseling will provide you with a revised notice by posting a revised copy in a prominent place in the waiting room, providing a copy at your next therapy session (if applicable), and making the revised copy available on our webpage: www.adulteencounseling.com

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Adulteen Counseling provides compassionate and affordable mental health counseling for adults, teens, children and families in River Falls, Hudson, and neighboring communities in the St. Croix River Valley of Wisconsin. 

Adulteen Counseling, llc

215 N 2nd Street, Suite 109

River Falls, WI 54022

Ph: 715-629-7047  F: 651-925-0052

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