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Carter-Hargrove, Inc.


Protecting Your Confidential Health Information Is Important to Us


This notice is not meant to alarm you. Quite the opposite! utilizing, examining, and analyzing information that identi-
It is our desire to communicate to you that we are taking fies you.
Disclosure applies to activities outside of my [office,
seriously Federal law (HIPAA Health Insurance Portabili- clinic, practice group, etc.], such as releasing, transferring,
ty and Accountability Act) enacted to protect the confiden- or providing access to information about you to other par-
tiality of your health information. We never want you to lay ties.
treatment because you are afraid your personal health
history might be unnecessarily made available to others Uses and Disclosures Requiring Your Permission
outside of our office. I may use or disclose PHI for purposes outside of treatment,
payment, and health care operations when your appropriate au-
How your HEALTH INFORMATION may be used to Pro- thorization is obtained. An authorization is written permis-
vide Treatment sion above and beyond the general consent that permits only
specific disclosures. In those instances when I am asked for
We may use or disclose your protected health information information for purposes outside of treatment, payment and
(PHI), to provide you treatment, to obtain payment, and to health care operations, I will obtain an authorization from you
conduct health care operations (e.g. scheduling, etc.) within our before releasing this information. I will also need to obtain an
office with your consent. To help clarify these terms, here are authorization before releasing your psychotherapy notes. Psy-
some definitions: chotherapy notes are notes I have made about our conversa-
PHI refers to information in your health record that tion during a private, group, joint, or family counseling session,
could identify you. which I have kept separate from the rest of your medical re-
Treatment, Payment and Health Care Operations cord. These notes are given a greater degree of protection than
Treatment is when I provide, coordinate or manage PHI.
your health care and other services related to your
health care. An example of treatment would be when I You may revoke all such authorizations (of PHI or psychother-
consult with another health care provider, such as your apy notes) at any time, provided each revocation is in writing.
family physician or another psychologist. You may not revoke an authorization to the extent that (1) I
- Payment is when I obtain reimbursement for your have relied on that authorization; or (2) if the authorization was
healthcare. Examples of payment are when I disclose obtained as a condition of obtaining insurance coverage, and
your PHI to your health insurer to obtain reimburse- the law provides the insurer the right to contest the claim under
ment for your health care or to determine eligibility or the policy.
- Health Care Operations are activities that relate to Uses and Disclosures with Neither Your Consent nor Your
the performance and operation of my practice. Exam- Permission
ples of health care operations are quality assessment
and improvement activities, business-related matters I may use or disclose PHI without your consent or authoriza-
such as audits and administrative services, and case tion in the following circumstances:
management and care coordination.
Use applies only to activities within my [office, clinic, Child Abuse: If I have reasonable cause to believe that a
practice group, etc.] such as sharing, employing, applying, child has been abused or neglected, I must report this and
Carter-Hargrove Inc.
924 Pyramid Way (775) 331-5133
Sparks, NV 89431 FAX (775) 448-6161

Protected Health Information Sheet for Carter-Hargrove, Inc. - 1

relevant information, within 24 hours, to the Division of and denial process.
Child and Family Services, the county agency which pro- Right to Amend You have the right to request an
vides child welfare services or a law enforcement agency. amendment of PHI for as long as the PHI is maintained in
Adult and Domestic Abuse: If I have reasonable cause to the record. I may deny your request. On your request, I
believe that an older person has been abused, neglected, will discuss with you the details of the amendment pro-
exploited or isolated, I must make a report to the local of- cess.
fice of the Nevada Department of Human Resources Divi- Right to an Accounting You generally have the right to
sion of Aging Services, the police department or sheriff's receive an accounting of disclosures of PHI for which you
office, or other appropriate agency within 24 hours after have neither provided consent nor authorization (as de-
becoming aware of this information. scribed in Section III of this Notice). On your request, I
Health Oversight: If I receive a request from the Nevada will discuss with you the details of the accounting process.
Board of Psychological Examiners with respect to an in- Right to a Paper Copy You have the right to obtain a
quiry or complaint about my professional conduct, I must paper copy of the notice from me upon request, even if you
make available any record relevant to such inquiry. have agreed to receive the notice electronically.
Judicial or Administrative Proceedings: If you are in-
volved in a court proceeding and a request is made for in- Our Duties
formation about your diagnosis and treatment and the
records thereof, such information is privileged under state We are required by law to maintain the privacy of PHI
law, and I will not release this information without written and to provide you with a notice of my legal duties and
authorization from you or your legally-appointed represen- privacy practices with respect to PHI.
tative, or a court order. The privilege does not apply when We reserve the right to change the privacy policies and
you are being evaluated for a third party or where the eval- practices described in this notice. Unless I notify you of
uation is court-ordered. You will be informed in advance if such changes, however, I am required to abide by the
this is the case. terms currently in effect.
Serious Threat to Health or Safety: I may disclose confi- If we revise my policies and procedures, I will provide
dential information from your records if I believe such dis- you with a revised version either in person or by mail
closure is necessary to protect you or another person from
a clear and substantial risk of imminent, serious harm. I How You Can Complain
may only disclose such information and to such persons as
are consistent with the standards of my profession in ad- If you are concerned that I have violated your privacy rights, or
dressing such problems. you disagree with a decision I made about access to your re-
Workers Compensation: If you file a workers compen- cords, you may send a written complaint to the Secretary of the
sation claim, and if I provide treatment to you relevant to U.S. Department of Health and Human Services.
that claim, then I must submit to your employers insurer
or a third party administrator, a report on services ren- Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on April 14, 2003. I reserve the
Your Rights as a Patient right to change the terms of this notice and to make the new
notice provisions effective for all PHI that I maintain. I will
Right to Request Restrictions You have the right to re- provide you with a revised notice in person or by mail.
quest restrictions on certain uses and disclosures of pro- If applicable, I will limit the uses or disclosures that I will
tected health information about you. However, I am not make as follows:
required to agree to a restriction you request.
Right to Receive Confidential Communications by Alter- In connection with the treatment program or consultation in which I/we
native Means and at Alternative Locations You have am/are participating with James A. and/or Anne E. Carter-Hargrove,
the right to request and receive confidential communica- Ph.D. I/we acknowledge reviewing the above document and discussing
tions of PHI by alternative means and at alternative loca- this matter with him/her. In addition, We explicitly hereby consent to the
tions. (For example, you may not want a family member to following:
Circle One
know that you are seeing me. Upon your request, I will
Yes No I/We acknowledge that I/we have been informed of the informa-
send your bills to another address.) tion contained above (pages 1-2 inclusive).
Right to Inspect and Copy You have the right to in-
spect or obtain a copy (or both) of PHI in my mental health
and billing records used to make decisions about you for as
Signed: Date:
long as the PHI 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. On your
Signed: Date:
request, I will discuss with you the details of the request

Protected Health Information Sheet for Carter-Hargrove, Inc. - 2