NOTICE OF PRIVACY PRACTICES - Nature of Mind, PLLC

Jordan Torri, Psy.D.

This notice describes how health information may be used and disclosed and how you can get access to this information.

I. MY PLEDGE REGARDING HEALTH INFORMATION

I understand that health information about you and your health care is personal and I am committed to protecting this information. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by my practice, and describes your rights to the health information I keep about you as well as certain obligations I have regarding the use and disclosure of your health information.

II. 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 with your consent. You provide this consent when you sign the accompanying document, AGREEMENT FOR PSYCHOLOGICAL SERVICES. Here are some definitions to help clarify these terms:

  • ‘Use’ applies only to activities within my office such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you.

  • ‘Disclosure’ applies to activities outside of my office such as releasing, transferring or providing access to information about you to other parties.

  • ‘PHI’ refers to information in your health record that could identify you.

  • ‘Treatment’ refers to activities in which I provide, coordinate or manage your health care and other services related to your health care. An example of treatment is when I consult with another health care provider, such as your family physician or another psychologist, about your care.

  • ‘Payment’ refers to activities to obtain reimbursement for your health care. An example of payment is when I disclose your PHI to your health insurer to obtain reimbursement for my services or to determine eligibility or coverage.

  • ‘Health Care Operations’ are activities that relate to the performance and operation of my practice. Examples of health care operations are audits or quality assessments.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

I may use or disclose PHI for purposes outside of treatment, payment and health care operations when I obtain your authorization. An authorization is written permission above and beyond the general consent your provide by signing the AGREEMENT FOR PSYCHOLOGICAL SERVICES. If I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain your authorization before I release this information.

I will also need to obtain an authorization from you before releasing your psychotherapy notes. ‘Psychotherapy notes’ are notes which I have made about our conversation during a private, group, couples or family counseling session, and which I have kept separate from the rest of your medical record. These notes are given a greater degree of legal protection than general PHI.

You may revoke all authorizations for the release of PHI or psychotherapy notes at any time, provided each revocation is in writing. You may not revoke an authorization (1) to the extent that I have relied on that authorization for an action I have already performed; or (2) the authorization was a condition for obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR CONSENT OR AUTHORIZATION

I can use and disclose your PHI without your consent or authorization for the following reasons.

  • CHILD ABUSE: If I have reasonable cause to believe that a child has suffered abuse or neglect, I am required by law to report this to the proper law enforcement agency or to the Washington Department of Social and Health Services.

  • ADULT OR DOMESTIC ABUSE: If I have reasonable cause to believe that a vulnerable adult has been subjected to abuse, neglect, financial abandonment or neglect, I must immediately report this to the Washington Department of Social and Health Services. If I have reason to suspect that sexual or physical assault has occurred against a vulnerable adult, I must immediately report this to the appropriate law enforcement agency or to the Washington Department of Social and Health Services.

  • SERIOUS THREAT TO HEALTH OR SAFETY: I am legally permitted to disclose your confidential PHI to any person without authorization if I reasonably believe that this disclosure will avoid or minimize imminent danger to your health and safety. If I reasonably believe that disclosure of your PHI will avoid or minimize serious danger to the health or safety of any other individual, I am required to disclose this information.

  • WORKER’S COMPENSATION: With certain exceptions, if you file a worker’s compensation claim I must make available, at any stage of the proceedings, to your employer, your representative, and the Washington Department of Labor and Industries, all mental health information in my possession relevant to that particular injury in the opinion of the Department of Labor and Industries,

  • JUDICIAL OR ADMINISTRATIVE PROCEEDINGS: If you are involved in a court proceeding and a request is made for information about the professional services I have provided to you and for the records of these services, such information is privileged under state law and I will not release the information without (1) your written authorization or the authorization of your legal representative; or (2) a subpoena of which you have properly been notified and which you have not informed me that you are opposing; or (3) a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I will inform you in advance if this is the case.

  • HEALTH OVERSIGHT: If the Washington Examining Board of Psychology subpoenas me as part of its investigations, hearings or proceedings relating to the discipline of, or issue or denial of licensure to, state licensed psychologists, I must comply with its orders. This could include disclosing your relevant mental health information.

  • LEGAL DEFENSE: If you file a lawsuit against me, I may disclose relevant information in order to defend myself.

V. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PERSONAL HEALTH INFORMATION

  • LIMITS ON USES AND DISCLOSURES OF PHI: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

  • DISCLOSURES ABOUT SERVICES PAID OUT OF POCKET: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  • INSPECTION AND COPYING: You have the right to inspect or obtain a copy of your PHI and psychotherapy notes in my records for as long as the information is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.

  • AMENDMENT: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may deny your request.

  • ELECTRONIC COPY OF THIS NOTICE: You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail.

VI. MY OBLIGATIONS

  • I am required by law to maintain the privacy of your PHI and to provide you with 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.

VII. COMPLAINTS

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, please inform me immediately so that we can resolve the problem. If you are not satisfied with my response to your concerns, you may contact the Washington Department of Health, Examining Board of Psychology, 1300 Quince Street SE, Olympia, WA 98504-7869.