HIPAA Form

Tracey Middleton, D.PSc, MEd

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health.  This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics.  It also describes your rights regarding how you may gain access to and control your PHI.

I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices.  I reserve the right to change the terms of our Notice of Privacy Practices at any time.  Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time.   I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request, providing one to you at your next appointment or by email.

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

Without Your Authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations.   For each category of uses or disclosures I will explain what I mean and try to give some examples.  Not every use or disclosure in a category will be listed.   However, all the ways I am permitted to use and disclose information will fall within one of the following categories.

A. For Treatment. Your PHI may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services in my practice. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant or health care provider only with your authorization.

B. For Health Care Operations. I may use or disclose your PHI for health care operations. These uses and disclosures are necessary to run my practice and make sure that all of my clients receive quality care. For example, I may use medical information to review my treatment and services. For employee training or teaching purposes PHI will be disclosed only with your authorization.

C. Judicial and Administrative Proceedings. In any judicial or administrative proceeding, you have the right to refuse to authorize the disclosure of any communication between you and a social worker relating to your care and treatment. There are a few instances in which this privilege would not apply, and therefore, in which I could testify in the judicial or administrative proceeding. Specifically, I may disclose such communications during judicial or administrative proceedings, if (i) I determine that you need hospitalization or are a threat to yourself or to others;  (ii) the communications were made in the course of a court-ordered psychiatric examination;  (iii) you are a party to a case and you have introduced your mental or emotional state as an element of a claim or defense;  (iv) if the testimony is given in connection with a care and protection proceeding, or a petition to dispense with parental consent to adoption; (v) in connection with any malpractice action brought by you against me, where the disclosure is necessary for my defense;  (vi) if the communications relate to your ability to provide care or custody in a child custody or adoption case;  or (vii) if the communication were made in connection  with and during an investigation of allegations of child abuse, when I have made a report that I have reasonable cause to believe that child abuse is occurring; or (viii) if  I believe a child, a disabled person, or an elderly person in your care is suffering abuse or neglect.

D. In an Emergency. I may disclose your PHI to a physician who requests such records in the treatment of a medical or psychiatric emergency. For example, if you are unconscious and the doctor treating you needs to know details regarding your medical history in order to decide on a course of treatment for you, I would disclose the PHI necessary for the doctor to treat you during the emergency.   If it is not possible to obtain your consent to this disclosure, then notice of the disclosure will be provided to you as soon as possible.

E. As Required by Law. I may disclose your PHI as required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations.

F. If Required by Court Order. I may disclose your PHI in a judicial proceeding if required by Court order.

G. If Necessary Because of Threat to Health or Safety. I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  I may use or disclose your PHI to the extent which is necessary to protect your safety or the safety of others, if (1) you present a clear and present danger to yourself, or (2) you have communicated an explicit threat to kill or inflict serious bodily injury upon another person, and there is a basis for reasonable belief that the threat may be carried out. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization.

Revocation of Authorization. If you provide me with permission to use or disclose PHI about you, you may revoke that permission, in writing, at any time. If you revoke your authorization, I will no longer use or disclose medical information about you for the purposes covered by the written authorization.  However, I am unable to take back any disclosures that I have already made with your authorization.

YOUR RIGHTS REGARDING YOUR PHI

You, or your authorized representative, have the following rights regarding PHI that I maintain about you.  To exercise any of these rights, please submit your request in writing to me, Tracey Middleton, 1636 Waverly Way, Baltimore, MD, 21239.

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care.  Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would be reasonably likely to endanger the life or physical safety of you or another person. I may charge a reasonable, cost-based fee for copies. I will act on your request within thirty days of receiving your request.

  • Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me in writing to amend the information although I am not required to agree to the amendment.
  • Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures that I make of your PHI. This is a list of certain disclosures I have made of your PHI.  To make this request, you should submit it in writing to me [OR OTHER EMPLOYEE DESIGNATED AS PRIVACY OFFICER]. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information I use or disclosure about you for treatment, payment, or health care operations.  For example, you might request that particularly sensitive information (such as the existence of drug dependence) not be disclosed for any purpose. I am not required to agree to your request. To request restrictions, you must submit your request in writing to me. In your request, you must tell me (1) what information you want to limit, (2) whether you want to limit the use, disclosure, or both, and (3) to whom you want the limits to apply (for example, disclosures to your insurance carrier.)
  • Right to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail.
  • Right to a Copy of this Notice. You have the right to a paper copy of this notice.  You may ask me to give you a copy of this notice at any time.

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT ME AT: 443-805-6119.

If you believe I have violated your privacy rights, you have the right to file a complaint in writing with me or with the Office for Civil Rights, U.S. Department of Health and Human Services, Government Center, J.F. Kennedy Federal Building – Room 1875, Boston, Massachusetts 02203. Voice phone (617) 565-1340. Voice phone 443-805-6119. FAX (617) 565-3809. TDD (617) 565-1343.

We will not retaliate against you for filing a complaint. The effective date of this Notice is September 30, 2010.

PLEASE CLICK HERE FOR A PAPER HIPPA FORM.

BY FILLING IN AND SUBMITTING THE FORM BELOW, YOU ARE DIGITALLY SIGNING THIS HIPPA FORM

Upon submitting this form, please email Tracey directly to alert her to your form submission: tracey_middleton@verizon.net

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  • , have received a copy of and understand this Notice of Privacy Practices.