This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, explains HIPAA and its application to your PHI in greater detail.
The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.
The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without authorization:
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.
If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
If a patient files a worker’s compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.
I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment:
If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Louisiana Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Louisiana Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
Use and Disclosure of Protected Health Information:
For Treatment – I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
For Operations – I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.
Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am 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.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advanced and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.
Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.
HIPAA-compliant Zoom platform
Videoconferencing psychotherapy sessions are provided on my HIPAA-compliant Zoom platform. This platform allows for real-time video communication. You do not need your own Zoom account to join me in my “Zoom room.” However, you will need a computer with a video-camera. A day or so before the meeting, I will send you a Zoom link. At the time of the meeting, click on the link. A video screen will pop up. You may have to click on icons in the lower left corner of the video box to turn on your microphone and camera.
A variety of technological problems can cause delays in starting meetings or can interrupt a meeting. If case we lose our connection, you can call my home office at985-893-1248: Please provide the phone number that I can call in case our internet connection fails. Keep this phone charged and with you while we meet so that I may call you as needed. If we cannot successfully reconnect on the internet, we can reschedule or continue on the telephone.
The audibility of videoconferencing may not as good as in face-to-face meetings. My experience is that participants may need to ask each other to repeat what we each said. We will also be less able to observe each other’s’ body language. All of this can result in a less “felt” sense of each other as compared to meeting face-to-face. If you sense that I have missed your meaning or responded in an unhelpful way, please tell me as soon as possible so that we can work to repair the mis-communication or mis-step.
Communication via the internet cannot be guaranteed to be 100% secure. The following are steps that we can take to increase security and confidentiality.
The Zoom videoconferencing platform and its Epic software are HIPAA-compliant. Our meetings are encrypted with AES-256 bit encryption and dynamic password protected. You can read more about Zoom security here
We both agree not to record our videoconference meetings without explicit permission from both parties.
To prevent non-participants from joining our confidential meetings electronically, we must both secure the links to our Zoom meetings that I send to you via email. Ensure your email account and mobile device have secure passwords and ensure that you close your email platforms when not in use. I will do the same.
We both agree not to have any other people in the rooms where we hold our video-conference, unless explicitly discussed prior.
In my experience, interruptions at home tend to occur during videoconferencing sessions and we should anticipate these. We can limit interruptions by telling people in our homes that we are having a confidential meeting, closing the doors to our rooms, and by placing a “Do Not Disturb” sign on our doors. Nonetheless, people may forget and walk in, other phone lines and doorbells ring, pets make their presence known, etc.
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice in office during our session.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Louisiana Department of Health, or the Secretary of the U.S. Department of Health and Human Services.
My practice does not sell, rent, trade or otherwise disseminate externally any personal information about those visiting his web site. We do reserve the right to use the information for internal tracking and statistical analysis, including but not limited to determining the number of visitors to the site, analyzing which sections are most accessed, length of stay per visitor and number of repeat visits.
By continuing to browse my web site, you agree not to use any information obtained for any purpose that is illegal, unlawful, unethical or prohibited by copyright or this agreement. By continuing to browse the site, you also expressly agree that you do so at your own risk.
As a convenience to visitors, we may provide links to web sites operated by other organizations. Such links do not imply or convey endorsement of said organizations. Further, these organizations are not covered under this agreement and are solely responsible for the content, security, terms of use and privacy issues of their web sites. We are absolved from responsibility for any repercussions experienced on other linked web sites.