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Notice of Privacy

HIPAA: Notice of Privacy

Potomac State College of West Virginia University

Psychological Counseling Services

(304) 788-6976

Effective Date:  April 14, 2003  


Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information



I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations   


We may use or disclose your protected health information (PHI), for treatment, payment, and health care operationspurposes. To help clarify these terms, here are some definitions:


Payment is when we obtain reimbursement for your healthcare.

Health Care Operations are activities that relate to the performance and operation of this 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.

II.  Uses and Disclosures Requiring Authorization


We may use or disclose PHI for purposes outside of treatment, payment, and 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 we are asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information.  We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record.  These notes are given a greater degree of protection than PHI. 

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) We have relied on that authorization.

III.  Uses and Disclosures with Neither Consent nor Authorization


We may use or disclose PHI without your consent or authorization in the following circumstances: 

ý        Child Abuse: If we have reasonable cause to suspect that a child is abused or neglected, or if we observe a child being subjected to conditions that are likely to result in abuse or neglect, we are required by law to immediately report these circumstances to the West Virginia State Department of Human Services.  Also, if we believe the child has suffered serious physical abuse or sexual abuse, we must report to the Division of Public Safety and a law enforcement agency.


ý        Health Oversight: If the West Virginia Board of Examiners of Psychologists, its president or the ethics coordinator issues a subpoena requesting us to appear before them and to bring documents with us, we must comply. This could include your confidential mental health information.


ý        Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about your evaluation, diagnosis or treatment or the records thereof, such information may be privileged under state law, and we generally will not release information without your written consent or court order. The privilege would not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.


ý        Serious Threat to Health or Safety: We may release confidential information to protect against a clear and substantial danger of imminent injury by you to yourself or another.


ý        Worker's Compensation: If you file a worker's compensation claim, we may release to and discuss with your employer, or its representative, or with a representative of the West Virginia Worker's Compensation Division, your mental health history; any reports pertaining to the occupational injury or disease and to any prior related injury or disease containing detailed information as to your condition, treatment, prognosis and anticipated period of disability; and dates as to when you will reach or have reached your maximum degree of improvement or will be or was released to return to work.


ý        Change of Ownership:   In the event that Potomac State College of West Virginia University is sold or merged with another organization, your medical information/record will become the property of the new owner. 

IV.  Patient's Rights and Psychologist's Duties


Patient' Rights:

ý        Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.


ý        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.  


ý        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. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.


ý        Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request.  On your request, we will discuss with you the details of the amendment process.


ý        Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice).  On your request, we will discuss with you the details of the accounting process.


ý        Right to a Paper Copy - You have the right to obtain a paper copy of the notice from us upon request.


Psychologist' Duties:

ý        We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

ý        We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

ý        If revisions are made, you may request a copy of any revised notice of privacy practices by calling the Psychological Counseling Office at the above telephone number or by asking at one of your next visits to the office.  A copy of the current notice is posted in our office area.  Upon your first visit, we will provide you with a copy of this notice. 

V.  Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact Susan Kephart, M.S., Licensed Psychologist, at (304) 788-6976.


If you believe that your privacy rights have been violated and wish to file a complaint with this office, you may send your written complaint to Susan Kephart, M.S., Licensed Psychologist at Potomac State College of West Virginia University, 101 Fort Avenue , Keyser , WV 26726 . 


You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  The person listed above can provide you with the appropriate address upon request.


You have specific rights under the Privacy Rule.  We will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy 

This notice will go into effect on April 14, 2003 .

Revised:  6/04