Notice of Jeffrey Zimmerman, Ph.D.’s (Dr. Zimmerman’s) Policies and Practices
to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL 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
DR. ZIMMERMAN (and his professional and administrative staff) 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:
· “PHI” refers to information in your health record that could identify you.
· “Treatment, Payment and Health Care Operations”
– Treatment is when DR. ZIMMERMAN provides, coordinate or manage your health care and other services related to your health care. An example of treatment would be when a DR. ZIMMERMAN consults with another health care provider, such as your family physician or another psychologist.
– Payment is when DR. ZIMMERMAN obtains reimbursement for your healthcare. Examples of payment are when DR. ZIMMERMAN discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
– Health Care Operations are activities that relate to the performance and operation of DR. ZIMMERMAN’s professional practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
· “Use” applies only to activities within our practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
DR. ZIMMERMAN may use or disclose PHI for purposes outside of treatment, payment, or 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 DR. ZIMMERMAN is asked for information for purposes outside of treatment, payment or health care operations, DR. ZIMMERMAN will obtain an authorization from you before releasing this information.
You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) DR. ZIMMERMAN has already relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
DR. ZIMMERMAN may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse – If, in the ordinary course of our work DR. ZIMMERMAN, has reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had nonaccidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then DR. ZIMMERMAN must report this suspicion or belief to the appropriate authority.
· Adult and Domestic Abuse – If DR. ZIMMERMAN knows or in good faith suspects that an elderly individual or an individual, who is disabled or incompetent, has been abused, DR. ZIMMERMAN may disclose the appropriate information as permitted by law.
· Health Oversight Activities – If a State of Connecticut licensing board or the Department of Public Health is investigating DR. ZIMMERMAN, the board may subpoena records relevant to such investigation.
· Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and DR. ZIMMERMAN will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation or release of information is court ordered.
· Serious Threat to Health or Safety – If DR. ZIMMERMAN believes in good faith that there is risk of imminent personal injury to you or to other individuals or risk of imminent injury to the property of other individuals, DR. ZIMMERMAN may disclose the appropriate information as permitted by law.
· Worker’s Compensation – DR. ZIMMERMAN may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
IV. Patient’s Rights and DR. ZIMMERMAN’ Duties
· Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, DR. ZIMMERMAN is not required to agree to a restriction you request.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are a patient or client of the office. On your request, DR. ZIMMERMAN will send your bills to another address.)
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. DR. ZIMMERMAN may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, DR. ZIMMERMAN will discuss with you the details of the request and denial process.
· Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. DR. ZIMMERMAN may deny your request. On your request, DR. ZIMMERMAN will discuss with you the details of the amendment process.
· Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, DR. ZIMMERMAN will discuss with you the details of the accounting process.
· Right to a Paper Copy – You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.
DR. ZIMMERMAN’s Duties:
· DR. ZIMMERMAN is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.
· DR. ZIMMERMAN reserves the right to change the privacy policies and practices described in this notice. Unless DR. ZIMMERMAN notifies you of such changes, however, DR. ZIMMERMAN is required to abide by the terms currently in effect.
· If DR. ZIMMERMAN revises his policies and procedures (for which he reserves the right to do), DR. ZIMMERMAN will provide you with a revised notice by directly handing it to you if you are actively seen in his office at that time.
If you are concerned that DR. ZIMMERMAN may have violated your privacy rights, or you disagree with a decision DR. ZIMMERMAN made about access to your records, you may contact him to discuss this matter further. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
This notice will go into effect on August 15, 2007.