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NOTICE OF POLICIES AND PRACTICES UTILIZED BY THE
CLINICAL PSYCHOLOGY CENTER
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

The Clinical Psychology Center (CPC) 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:

II.   Uses and disclosures requiring authorization

The CPC may use or disclose PHI for purposes outside of treatment, payment, and 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 the CPC is asked for information for purposes outside of treatment, payment, and health care operations, we will obtain an authorization from you before releasing this information.  The CPC will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes made about your conversation during private, family, or group counseling sessions, and when these exist, they are kept separate from the rest of your clinical record.  These notes are given a greater degree of protection than the PHI.  Further, the CPC will need to obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

You may revoke all authorizations regarding PHI and/or psychotherapy notes at any time, provided such revocation is in writing.  You may not revoke an authorization to the extent that (1) the CPC 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.  However, remember that the CPC does not currently accept insurance.

III.   Uses and disclosures with neither consent nor authorization

The CPC may use or disclose PHI without your consent or authorization in the following circumstances:

IV.   Client rights and CPC duties

CLIENT RIGHTS:

CPC DUTIES:

V.   Complaints

If you are concerned that the CPC has violated your privacy rights, or you disagree with a decision made by CPC staff about access to your records, you may contact Andrew Koffmann, Ph.D., Director, CPC, at 412-624-2077.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  Dr. Koffmann can provide you with the appropriate address upon request.

VI.   Effective date, restrictions, and changes to privacy policy

This revised notice is in effect as of August 1, 2013.


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