HIPAA Forms

Following the links below is the (shorter) HIPAA summary:

 

Click here for a printable HIPAA-compiant release form (if you want to release me to speak with someone specific).

Click here for shorter HIPAA policies summary in printable format.

Click here for the full HIPAA policy in printable format.

Click here for HIPAA patent agreement (your assent to HIPAA’s rules) in printable format.

(Click here for full HIPAA document on this page).

(Click here for a copy of a HIPAA compliant release form on this page.)

 

Rick Blum, Ph.D., Licensed Psychologist

8 Arapahoe Road, P.O. Box 270682

West Hartford  CT  06127-0682

(860) 233-1897

 

Notice of Privacy Practices Summary

 

 

The following is a required “notice of privacy practices” (NPP) in keeping with Federal HIPAA requirements.

 

Overview of privacy issues:

The laws regarding privacy of personal health information are complicated.  Federal regulations require your approval of a full NPP as part of receiving health services.  To accomplish this, I will provide you with a copy of the full, legally required NPP and this shorter version, which summarizes the same information.   Finally, there is a standard consent form that documents your agreement with the NPP.  I am not permitted to provide treatment without an executed consent form.  You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these.

 

The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, in the law, “health care operations.”  Before private information can be disclosed (sent, shared, or released) for any additional purposes, a separate authorization form is required to allow it.

 

Your health information is private and will be kept that way, but there are some times when the law requires disclosure.  For example:

 

  1. When there is a serious threat to your health or safety or the health or safety of another individual or the public.  Information would then be shared with a person or organization that is able to help prevent or reduce the threat.
  2. Some lawsuits and legal or court proceedings.
  3. If a law enforcement official requires to do so.
  4. For Workers Compensation and similar benefit programs.
  5. There are some other situations like these but which happen very rarely.  They are described in the longer version of the NPP.

 

 

 

[over]

 

 

 

 

 

 

Your rights regarding your health information

 

  1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy.   For example, you could ask me to call you at home and not a work to schedule or cancel an appointment.  I will try my best to do as you ask.
  2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends.   If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.
  3. You have the right to look at your health information, such as billing records or health records, such as psychotherapy notes.  You can even get a copy of these, provided that you reimburse for time and copy expenses involved.
  4. If you believe that any information in your records is incorrect or missing important information, you can ask to have some kinds of changes (termed “amending”) to your health information.  You would have to make such a request in writing and send it to the office, and you would also need to write the reasons that you want to make the changes.
  5. You have the right to a copy of this notice and to the longer NPP.  If I make any changes to either form, I will post the new version in the waiting room, and you could always get a copy of the new NPP from me.
  6. You have the right to file a complaint if you believe that your privacy rights have been violated.  You can file such a complaint with me personally and with the Secretary of the Department of Health and Human Services.  All complaints must be in writing.  Filing a complaint regarding privacy will not in itself change the health care that you receive at this office.

 

If you have any questions regarding this notice or the health information privacy policies at this office, please contact Dr. Rick Blum, as the Privacy Officer for the purposes of the above issues.  The telephone number and address is on the letterhead on the other side.

 

The effective date of  this notice is April 14, 2003.

 

 

Full HIPPA Document

Rick Blum, Ph.D.

 

Licensed Psychologist

8 Arapahoe Road

West Hartford  CT  06107

(860) 233-1897

Notice of Privacy Practices – Full Version (NPP)

 

Privacy is a very important concern.  It is also complicated because of the many federal and state laws that apply.  For example, we are required to provide this lengthy notice and to secure your written consent to it.  Because the rules are so complicated, some parts of this NPP form are very detailed.  If you have any questions, Dr. Blum, as “privacy officer,” will be happy to help you understand the procedures and your rights.

 

Contents of this NPP
A.    Introduction
B.     What we mean by your medical information
  1. Privacy and the laws about privacy.
  2. How your protected health information can be used and shared
    1. Uses and disclosures with your consent
      1. i.      The basic uses and disclosures – For treatment, payment, and health care operations (TPO)
      2. ii.      Other uses and disclosures in health care
    2. Other uses and disclosures that require your authorization
    3. Uses and disclosures that don’t require your consent or authorization
    4. Uses and disclosures where you have an opportunity to object
    5. An accounting of disclosures we have made

E.If you have questions or problems

 

Introduction

This NPP (Notice of Privacy Practices) will tell you how we handle your medical information.  It tells how we use this information in this office, how we share it with other professionals and organizations, and how you can see it.   This form lists both some common and some very rare uses of health information as applied to a psychotherapy practice.  Because the laws of the state and the federal government are very complicated, and despite the level of detail of this form, there are still small parts of the law that are not represented here.  You can request more information from the Privacy Officer.

 

What we mean by your medical information

Each time you visit the office of any healthcare provider, information is collected about you and your physical and mental health.  It may be information about your past, present or projected future health or conditions, or the tests or treatment that you have received or will receive, or about payment for healthcare.  Such information is called, in the law, PHI, which stands for “protected health information.”  This information is kept in a medical record.

 

In this office, your PHI may include these kinds of information:

  • Your history, as a child, in school or work, marriage or personal history.
  • Reasons you came for treatment, including stated problems, complaints, symptoms, or needs.
  • Diagnoses, which are medical terms for problems or symptoms.
  • A treatment plan, including services that we think will be helpful for you.
  • Progress notes, which are required notations about how you are doing, what we notice, and what you say.
  • Records we receive from others who treated or evaluated you.
  • Psychological test scores, school records, and other reports.
  • Information about medications you took or are taking.
  • Legal matters.
  • Billing and insurance information.

This list is just to give you an idea of anticipated information, but there may be other kinds of information that also go into your healthcare record.

 

The purpose of collecting and keeping such information includes using it:

  • To plan your care and treatment.
  • To decide how well our treatment is working for you.
  • To talk with other healthcare professionals who are also treating you such as your family doctor or the professional who referred you to us.
  • To show that you actually received the services from us that we billed to you or to your health insurance company.
  • For teaching and training other healthcare professionals.
  • For medical or psychological research.
  • For publishing case studies for educational purposes.
  • For public health officials trying to improve health care in this area of the country.
  • To improve the way we do our job by measuring the results of our work.

 

When you understand what is in your record and what it is used for you, can make more informed decisions about who, when, and why others should have this information.

 

Although your health record itself is the physical property of the healthcare practitioner or facility that collected it, the information that is in it belongs to you.  You can read it, and if you want a copy we can make one for you, but we may charge you for the costs of copying and mailing, if you want it mailed to you.  In some very rare instances you cannot see all of what is in your records.  For example, if a psychotherapist believes that an element of the record could be emotionally damaging for a patient to read, the record might be shared only with a professional who will interpret the record for the patient.  If you find anything in your records that you think is incorrect or believe that something important is missing, you can ask us to amend your record, although in some rare situations we might not agree to do that.  The Privacy Officer can explain more about this, at your request.

 

Privacy and the laws

We are also required to tell you about privacy because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The HIPAA law requires us to keep your PHI private and to make this notice available to you to inform you of our legal duties and our privacy practices, which is called the Notice of Privacy Practices (NPP).  We will obey the rules of this notice as long as it is in effect, but if we change it then the rules of the new NPP will apply to the entire PHI we keep.  If we change the NPP, we will post the new NPP in the waiting room.  You or anyone else can also get a copy from our Privacy Officer at any time.

 

How your protected health information can be used and shared

When an individual inside this office reads your information, this is called, in the law, “use.”  If the information is shared with or sent to others outside the office, that is called, in the law, “disclosure.”  Except in some special circumstances, when we use your PHI here or disclose it to others, we share only the minimum PHI needed for the purpose it is being used.  The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed.  So, this notice will next detail uses and disclosures of PHI.

 

Uses and disclosures of PHI with your consent:  After you have read this NPP, you will be asked to sign a separate consent form to allow us to use and share your PHI for certain purposes.  In almost all cases we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, to arrange for payment for our services, and some other business functions called heath care operations.  Together these routine purposes are called TPO, and the Consent Form allows us to use and disclose your PHI for TPO.  TPO is detailed next.

 

For treatment, payment, or health care operations:  We need information about you and your concerns to provide services to you.  You have to agree to let us collect the information and to use it and share it to provide appropriate care.  This is why you must sign the Consent Form before we begin to treat you, because if you do not consent, we are not permitted to treat you.  Generally, we may use or disclose this PHI for three purposes:  treatment, obtaining payment, and what are called healthcare operations.

 

For treatment:  We use your healthcare information to provide you with psychological treatment.  These might include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the benefits of our services.  We may disclose your PHI to others who provide treatment to you.  For example, this could be your personal physician.  We may refer you to other professionals or consultants for services we cannot provide.  We will get back their findings and opinions, and those will be referenced in your records here.  If you receive treatment in the future from other professional, we can also share your PHI with them.   These are some examples so that you can see how we use and disclose your PHI for treatment.

 

For payment:  We may use your information to bill you, your insurance, or others so we can be paid for the services we provide to you.  We may contact your insurance company to check on exactly what your insurance covers.  We may have to tell them about your diagnoses, what treatment you have received, and the charges we expect in your situation.  We will need to tell them about when we met, your progress, and other similar things.

 

For heath care operations:  There are a few other ways we may use or disclose your PHI for what are called health care operations.  For example, we may use your PHI to see where we can make improvements in the services we provide.  We may be required to supply some information to some government health agencies so that they can study certain problems and treatment and make plans for services that are needed.  If we do, your name and personal information will be removed from what we send.

Other uses in healthcare:  We may use or disclose medical information to reschedule or remind you of appointment for treatment or other care.  You can ask us to call or write to you only at your home or your work or some other way to reach you.  We may use or disclose your PHI to tell you about or recommend possible treatment alternatives, health-related benefits, or services that may be of interest to you.  If we do research, if we publish research results, of if we write about cases for publication we may disclose your PHI, but your name, address, and other personal information will be removed in such cases.  There are some jobs that other businesses provide for us.  In the law, they are called business associates.  Examples include a copy service that makes copies of health records and a billing service that figures out, prints, and mails our bills.   These business associates need to receive some of your PHI to do their jobs.  To protect privacy, they are contracted with us to safeguard your information.

 

Uses and disclosures that require your authorization:  If we want to use your PHI for any purpose besides the TPO or those uses we described above, we need your permission on an Authorization Form.  We do not expect to typically have a need for this.  It would usually occur if you desired us to disclose PHI, for some purpose, to an organization or individual not included above.

 

Uses and disclosure of PHI that do not require either a Consent or Authorization Form:  The law allows or requires us to use and disclose some of your PHI without your consent or authorization in some cases.  Here are examples of when we might have to share your information.

 

When required by law:  There are some federal, state, or local laws that require us to disclose PHI.

  • We have to report suspected child abuse.
  • If you are involved in a lawsuit or legal proceeding and we receive a subpoena, discovery request, or other lawful process, we may have to release some of your PHI.  We will only do so after trying to tell you about the request, consulting your lawyer, or trying to get a court order to protect the information they requested.  In this way, I would attempt to assert your privacy rights.
  • We have to disclose some information to the government agencies that check on us to see that we are obeying the privacy laws.

 

For law enforcement purposes:  We may release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.

 

For public health activities:  We might disclose some of your PHI to agencies that investigate diseases or injuries.

 

We might disclose PHI to coroners, medical examiners, or funeral directors, and to organizations relating to organ, eye, or tissue donations or transplants.

 

For specific government functions:  We may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment.  We may disclose your PHI to Workers Compensation and Disability programs, to correctional facilities if you are an inmate, and for national security reasons.

 

To prevent a serious threat to health or safety:  If we come to believe that there is a serious threat to your health or safety or that of another person or the public we can disclose some of your PHI.  We will only do this to persons who may be able to prevent the danger.

 

Uses and disclosures where you have an opportunity to object:  We can share some information about you with your family or close others.  We will only share information with those involved in your care and anyone else you choose such as close friends or clergy.  We will ask you about whom you want us to tell what information about your concerns or treatment.  You can tell us what you want and we will honor your wishes as long as it is not against the law.  If it is an emergency – so that we cannot ask if you disagree – we can share information if we believe that it is what you would have wanted and if we believe it will help you if we do share it.  If we do share information in an emergency, we will tell you as soon as we can.  If you do not approve, we will stop as long as it is not against the law.

 

An accounting of disclosures:  When we disclose your PHI, we may keep records of whom we sent it to, when we sent it, and what we sent.  You can get an accounting (list) of many of these disclosures.

 

If you have questions or problems

If you need more information or have questions about the privacy practices described above, please speak to Dr. Richard Blum as the Privacy Officer, using contact information on the letterhead on the first page.  If you have a problem with how your PHI has been handled or if you believe you privacy rights have been violated, contact the Privacy Officer.  You have the right to file a complaint with us and with the Secretary of the federal Department of Health and Human Services.  We promise that will not in any way limit your care here or take any actions against you if you complain.

 

The effective date of this notice is April 14, 2003.

 

HIPPA-compliant Release Form:

RICHARD B. BLUM, PH.D.
Licensed Psychologist

8 Arapahoe Road

West Hartford, Connecticut  06107

Phone:  (860) 233-1897

 

 

 

Authorization to use and disclose protected health information

  1. 1.   I am completing this form to allow the use and sharing of protected health information about:

Printed name:  _______________________   Date of Birth:  ___________

  1. 2.   I authorize this person or organization_____________________________________________________________________

3a.  To use or disclose the following information:

  • Inpatient or outpatient treatment records for physical and/or psychological, psychiatric, or emotional illness.
  • Admission and discharge summaries
  • Psychological or psychiatric evaluation(s), reports, assessments, treatment notes, summaries, or other documents with diagnoses, prognoses, recommendations, or testing records, and behavioral observations or checklists completed by any staff member or the patient, or similar documents.
  • Treatment, recovery, rehabilitation, aftercare plans and other similar plans.
  • Social, family, educational, and vocational histories.
  • Social work assessments, occupational therapy and vocational reports, and evaluations
  • Progress, Nursing, Case or similar notes.
  • Evaluations and reports of consultants.
  • Information about how the patient’s condition(s) affects or has affected his or her ability to work, and to complete tasks or activities of daily living.
  • Billing records.
  • Academic and educational records, including achievement and other test results, reports of teachers’ observations, and all other school or special education documents.
  • HIV-related information and drug and alcohol information contained in these records will be released under this authorization unless indicated here –
    • do not release these.
    • Other information:  _________________________________________

 

__________________________________________________________________

 

3b.   Dates of care included:  From _______________ to _____________________

 

4. To this person or organization________________________________________

 

____________________________________________________________________

 

5.  The information will be used/disclosed for the following purposes:  [next page}

 

__________________________________________________________________________________

 

__________________________________________________________________________________

 

6.  I understand and agree that this Authorization will be valid and in effect until

 

______________________________________________________________________.

I understand that after that date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one.

 

7. I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization listed above and which is to supply this information.   If I do this, it will prevent any disclosures after the date it is received but cannot change the fact that some information may have been sent or shared before that date.

 

8.  I understand that I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the professional or facility listed at number 2 above.

 

9.  I understand that I may inspect and have a copy of the health information described in this authorization.   There may be a cost for this copy or other services.

 

10.  I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by those regulations.

 

11.  I understand that the professional or facility listed in number 2, above, may receive compensation for the use or disclosure of my health information.  If that is the case, I understand and accept it.

 

12.  I affirm that anything in this form that was not clear to me has been explained adequately for my understanding.   I have also received a copy of this completed form

 

­­­­­­­­­­­­­­­­­­­­­­______________________________________________               __________________________

13.   Signature of client or his or her personal representative                     Date

 

______________________________________________    _____________________________

Printed name of person in item 13                                              Relationship to person in item 13

 

_________________________________________________________________________

Description of personal representative’s authority

 

  1. I, a mental health professional, have discussed the issues above with the client and/or personal representative.   My observations of his/her responses give me no reason to believe that this person is not fully competent to give informed and willing consent:

 

______________________________________  ________________________________ _____________

Signature of professional receiving authorization            Printed name                                              Date