Unity Care, P.C.
224 Penn Avenue, Suite 2A
Pittsburgh, PA 15221
Notice of Policies and Practices The Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Notice includes summary information about the Health Insurance Portability and Accountability Act (HIPAA) which is a federal law providing privacy protections and patient rights. Where asterisked (*), the document also includes updated HIPAA language and requirements effective 9/23/13. HIPAA requires that I provide you with this notice. The law also requires that I obtain your signature acknowledging that I have provided this information. Your signature on the Consent to Treatment form for your file will so acknowledge.
I have also included some specific information regarding my practice and policies.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. PHI is Information in your record that could identify you.
What is your PHI? Your PHI would be the information in your Clinical Record, or Patient File. This may include information about your reasons for seeking therapy, how your problems are impacting your life, your diagnosis, the goals of treatment, your progress, your medical and social history, your treatment history, any past records I may receive from previous providers, any reports from testing, etc., any billing and/or insurance authorization information, any reports to your insurance carrier.
Treatment includes providing care, coordinating care with another provider, your managed care insurer, etc. Payment involves release of information to your insurer. *By agreeing to treatment and/or assessment with Unity Care, P.C., you are also agreeing to have your PHI released electronically to clearinghouse and billing entities that manage our insurance claims. Electronic billing entities and clearinghouses are also subject to the same confidentiality and privacy statutes as practitioners. However, as the practitioner for your treatment, it is the responsibility of Unity Care, P.C. to ensure that they take the appropriate measures and remain in compliance with HIPAA laws regarding release of PHI.
Health Care Operations might be something like an audit, and refers to activities that relate to the performance of my practice.
Your general consent on the Consent to Treatment form permits disclosure of your PHI for the above purposes. The Privacy Rule also requires that for any purpose only the Minimum Necessary information be provided. In order to ensure that only necessary information is released to necessary entities, no information will be released without your written consent except in instances designated below in section III, or for the purposes of billing and insurance as is described above.
II. Uses and Disclosures Requiring Authorization
I 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 described above. It permits only the specific authorized disclosure to the specific authorized person or entity. In any instance when I am asked for information from your Clinical Record for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information.
In addition to your Clinical Record (or Patient File), which is your PHI, I also keep what are called Psychotherapy Notes. The content of Psychotherapy Notes varies from patient to patient. They are to assist me in your treatment and may include more specific information such as, the contents of our conversations, my analysis of those conversations, sensitive information that you reveal or provide in written form, etc. These Psychotherapy Notes are kept in a separate file from your Clinical Record (or Patient File). They are NOT considered PHI. They are not available to you and cannot be sent to anyone (including insurance companies) without your specific, signed Authorization. The HIPAA Privacy Rule gives this information an even greater degree of protection than your PHI.
You may revoke all Authorizations at any time, in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
* Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require patient authorization. Other uses and disclosures not described in the Privacy Notices will be made only with authorization from you. In general, my practice is that I will only use or disclose your PHI with express-written consent from you, and we will discuss the circumstances that would surround such disclosure prior to written consent.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
IV. Patient’s Rights and Psychologist’s Duties
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, please so advise me in writing and we will discuss.
If you are not satisfied at that time, you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
This notice will go into effect on September 23, 2013. This is the date that the HIPAA Privacy Rule amendments go into effect.
VII. Other Information Regarding My Practice and Policies
Fees: My hourly fee is $130.00 per hour. If I participate with your insurance carrier, I accept the fee allowed under the insurance plan. You are responsible for any co-payments, deductibles, and/or any portion of my fees that is not reimbursed by your insurance company for any reason.
Insurance Reimbursement: You are responsible for full payment of my fees, not your insurance company. I will assist you by submitting claims, obtaining authorizations, submitting treatment plans, etc. However, any insurance you have is an agreement the carrier has made with you. Please be sure you understand your plan and what it will and will not cover, as you are responsible for any amount they do not pay.
Contacting Me: My phone number is answered by my answering service 24 hours a day. I will make every effort to return your calls within 24 hours. In the event of an emergency you should ask my answering service to page me, and I shall make every effort to return your call within a few hours. If you are ever unable to reach me and/or feel that you can’t wait, contact your family physician or the nearest emergency room. If I am ever unavailable for an extended time, I will provide my answering service with the name and number of a colleague to contact, if necessary.
*Business Associates: If, when, I rely on a person or entity (who is not my employee) to provide services for me, they may require disclosure of some portion of PHI to perform the service. This might be a billing person, the answering service, a lawyer, an accountant or collection agent, etc. Under the Privacy Rule, any such individual is considered my business associate. I enter into a written agreement with each of my business associates to obtain satisfactory assurance that the business associate will safeguard the privacy of the PHI of my patients. *I am responsible for any breaches or violations of this policy that might be the result of my business associates. Please ensure that you notify of any concerns regarding your PHI in these contexts.