The Doctors, Clinical Psychologists, Psychiatric Social Workers, Therapists and other staff members working with the organization is bound by the ethical rules of our professional organization and will maintain confidentiality.
What Information is Protected
Protected Health Information. The Privacy Rule protects all "individually identifiable health information" held or transmitted by the organization or its business associate, in any form or media, whether electronic, paper, or oral.
“Individually identifiable health information” is information, including demographic data, that relates to:
- the individual’s past, present or future physical or mental health or condition,
- the provision of health care to the individual, or
- the past, present, or future payment for the provision of health care to the individual,
and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date).
Permitted Uses and Disclosures
The organization may use or disclose the data collected only under the following circumstances:
(1) To the Individual :The organization may reveal the information to the individual who is the subject of the collected information upon their request.
(2) Treatment, Payment, Health Care Operation: the organization may disclose or use the private health information for its own treatment, payment, and health care operations activities.
Treatment is the provision, coordination, or management of healthcare and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.
Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.
Health care operations: They any of the following activities: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information.
Most uses and disclosures of psychotherapy notes for treatment, payment, and health care operations purposes require an authorization as described below. Obtaining “consent” (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations).
The content of a consent form, and the process for obtaining consent, are at the discretion of the Organization.
(3) Uses and Disclosures with Opportunity to Agree or Object: Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, organizations generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.
Facility Directories: IThe organization will maintain a directory of patient contact information. The organization will rely on an individual’s informal permission to list in its facility directory the individual’s name, general condition, religious affiliation, and location in the provider’s facility.The provider may then disclose the individual’s condition and location in the facility to anyone asking for the individual by name provide they prove their association with the individual.
For Notification and Other Purposes: The organization also may rely on an individual’s informal permission to disclose to the individual’s family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person’s involvement in the individual’s care or payment for care. This provision, for example, allows a pharmacist to dispense filled prescriptions to a person acting on behalf of the patient. Similarly, the organization may rely on an individual’s informal permission to use or disclose protected health information for the purpose of notifying (including identifying or locating) family members, personal representatives, or others responsible for the individual’s care of the individual’s location, general condition, or death. In addition, protected health information may be disclosed for notification purposes to public or private entities authorized by law or charter to assist in disaster relief efforts.
(4) Incidental Use and Disclosure: The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as “incident to,” an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the “minimum necessary,” as required by the Privacy Rule.
(5) Public Interest and Benefit Activities: The Privacy Rule permits use and disclosure of protected health information, without an individual’s authorization or permission, for national priority purposes. These disclosures are permitted, although not required, by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest needed for this information.
Required by Law: Covered entities may use and disclose protected health information without individual authorization as required by law (including by statute, regulation, or court orders).
Public Health Activities. Covered entities may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance.
Victims of Abuse, Neglect or Domestic Violence. The organization may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
Judicial and Administrative Proceedings. The organization may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.
Law Enforcement Purposes. The organization may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if the covered entity suspects that criminal activity caused the death; (5) when The organization believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.
Serious Threat to Health or Safety. The organization may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat (including the target of the threat). The organization may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal.
(6) Limited Data Set: A limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set.